1 / 32

Investigation and Management of the Febrile Surgical Patient

Investigation and Management of the Febrile Surgical Patient. Victoria Hall Intern. The page. “Mr Jones in 3SW Bed 44 has just spiked a fever. Please review....”. What do you want to know over the phone?. What do you want to know over the phone?.

dot
Download Presentation

Investigation and Management of the Febrile Surgical Patient

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Investigation and Management of the Febrile Surgical Patient Victoria Hall Intern

  2. The page..... “Mr Jones in 3SW Bed 44 has just spiked a fever. Please review....”

  3. What do you want to know over the phone?

  4. What do you want to know over the phone? • Clarify what “fever” is – what was the recorded temperature? • How long have they had the temperature for? • What are their other vital signs? • What day post-op is the patient? • What was the reason for admission/ what surgery did they have? • Are they able to help you out and start taking bloods?

  5. The reply... • “Not really sure how long they have had the fever for. He was admitted the other day, I think his surgery was three days ago. He doesn’t look himself. His family are worried actually....His temperature is 38.1, BP 105/60, HR 90, RR 20. I’ll see what I can do about the bloods...”

  6. And in your mind...

  7. And in your mind... • How sick is this patient? • Do they need urgent review (haemodynamically unstable/are they met call criteria?) • After your review - does the surgical registrar need to know about this patient/do you need help?

  8. What classifies as fever? • Rectal temperature > 38ºC • Oral temperature > 37.8ºC • Axillary temperature >37.2ºC • Tympanic membrane temperature > 37.5ºC • Beware of the elderly patients “the older the colder”, and immuno-suppressed

  9. What is the mechanism behind fever? • Manifestation of cytokine release in response to a number of stimuli • IL-1, IL-6, TNF-alpha, IFN-gamma • Some evidence that IL-6 is most closely correlated with post-operative fever • Fever-associated cytokines are released by tissue trauma • The magnitude of the trauma : degree of the fever response • Bacterial endotoxins and exotoxins translocated from the colon can stimulate cytokine release and cause postoperative fever • NSAIDs and glucocorticoids suppress cytokine release and thereby reduce the magnitude of the febrile response

  10. Systemic Inflammatory Response Syndrome SIRS is the clinical syndrome that results from a dysregulated inflammatory response to a non-infectious insult, such as an autoimmune disorder, pancreatitis, vasculitis, thromboembolism, burns, or surgery. Two or more of the following be present: • Temperature >38.3ºC or <36ºC • Heart rate >90 beats/min • Respiratory rate >20 breaths/min or PaCO2 <32 mmHg • WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms

  11. What day post op is the patient? • Day 1-2: unlikely to be an infection, often related to inflammatory stimulus of surgery • Day 2 -7 : nosocomial infections – pneumonia (ventilator associated or aspiration), urinary tract infection, intra-vascular catheters, non-infectious causes • Day 7 +: wound infection, antibiotic-associated diarrhoea (ie C.Difficile) • Delayed (often discharged home): wound infection, implanted medical devices, infective endocarditis

  12. Atelectasis as a CAUSE of fever? • Both occur frequently after surgery • Their concurrence is probably coincidental rather than causal • Studies of abdominal surgery patients have found that there was no association between fever and the presence of, or the degree of, atelectasis [73].

  13. Fever does not always mean infection! • What are the non-infectious causes of acute fever in the surgical patient?

  14. Non-infectious causes of fever... • P.E. • DVT • Pancreatitis • Myocardial infarction • Acute gout • Alcohol withdrawal • Iatrogenic: medications (antibiotics, heparin), transfusion reaction, drug-drug interactions (ie serotonin syndrome)

  15. Approach to the febrile surgical patient • Quick bedside “look” test – are they well or unwell? • What are their vital signs? Is it actually a fever? • Are they haemo-dynamically stable? • What is their RR (measure it yourself...)? • Have they had previous fevers? What is the trend?

  16. Approach to the febrile surgical patient • Take a history! What do you want to know? • Keep an open mind • Read through their inpatient notes, look at their medication charts – are they on antibiotics? Were they previously on antibiotics?

  17. History... History of the fever, associated chills or rigors? Malaise, lethargy, decreased exercise tolerance Associated symptoms... • Chest: cough, sputum, dyspnoea, haemoptysis, wheeze, pleuritic chest pain • Meningism: neck stiffness, photophobia, headache, seizure • Urinary: dysuria, haematuria, frequency • Abdominal: pain, nausea, vomiting, diarrhoea, ileus

  18. History... • Wound/IVC: tender, erythema, purulent discharge, wound breakdown • Skin: rash, splinter haemorrhages • Joint exam: red, swollen joint, tender, decreased ROM/mobility, pain • Mental state – are they able to give you a history? Are they in a delirium? (and could this be the cause?)

  19. History... Other clues... • What was the reason for admission? • Are they immuno-compromised? Is the patient a diabetic? • Any exotic travel recently? • Have they received DVT prophylaxis whilst an inpatient? Has it been administered? • What is their risk for PE? • What medications are they on? Could this be a drug fever?

  20. Approach to the febrile surgical patient • Thorough examination – you are looking for clues/source of the fever... • Including bedside tests – ECG, urine dipstick

  21. On Examination... • Use the history to guide you • A,B, C • Look for signs of shock: mental state, peripheries / capillary refill, hourly urine output • Rash • IV access sites • Surgical wound(s)/biopsy site • Do they have a catheter in? What colour urine is it draining?

  22. On Examination... • Proper physical examination: Cardio-respiratory, abdominal, neurological, joint – what are you looking for? • Tender calves? • Blood transfusion?

  23. What investigations do you need to perform? • Be guided by history and examination • I’m going to order a “full septic screen”... • And other tests?

  24. Investigations... • Bloods: FBE, UEC, CRP, Coagulation profile, Blood cultures +/- LP for CSF analysis • BSL • ABG • Urine dipstick + MCS • Wound swab • Catheter tip/ IVC tip • CXR • ECG • ? CTPA (consider it!) • Others for non-infectious causes

  25. Management • In any acute situation - always remember ABC • If they are unwell and you are worried – tell someone! • Good documentation = good doctor

  26. Management • ABC • A: patent, no obstruction evident, speaking in full sentences • B: keep SaO2 >90%, (CO2 retainers 88-92%), ABG can give answers! • C: If hypotensive -> wide bore IV access, fluid bolus (watch for the patient with CCF) • D: What is their GCS? Are they at risk of airway collapse? Are they delirious? • Remember BSL...

  27. Management • Be guided by your likely diagnosis • Remove offending treatment – ie medications causing drug fever, IDC, intra-vascular access sites... • Regular paracetamol will provide comfort and minimise physiologic stress of fever

  28. If you suspect infection... Be guided by Surviving Sepsis Campaign: • Early resuscitation and antibiotics • Isolates before antibiotics (which means 2 sets of blood cultures separated in time and place) • Strong recommendation for crystalloid as initial fluid resuscitation (1L or more) – and watch for response • Weak recommendation for albumin with crystalloid for severe sepsis and septic shock • Usually broad spectrum antibiotics, appropriate to suspected source of infection – within one hour of diagnosis of septic shock or severe sepsis without shock • Narrow spectrum once microbiology results become available

  29. Which antibiotic? • Often difficult decision • Use local hospital guidelines/clinician preference for recommended antibiotics • Think about what you are targeting, previous antibiotic exposure, immuno-competency of the patient and how severe the infection is

  30. Management • Review, review, review • The patient and their results • Are they improving or getting worse? • Have they responded to your fluid challenge? • Do you need to re-think your initial diagnosis? • Handover!

  31. Any questions?

  32. References • Weed HG, Baddour LM, Up To Date 2012, Postoperative fever. Viewed Oct 8 2012. Available at URL www.uptodate.com • Neviere R, Up To Date 2012. Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis. Viewed Oct 8 2012. Available at URL www.uptodate.com • Cadogan M, Brown FT, Celenza T, 2011, Marshall and Ruedy’s On Call – Principles and Protocols, 2nd Edition, Saunders Australia. • Surviving Sepsis Campaign 2008, Surviving Sepsis Campaign Guidelines. Viewed Oct 8 2012. Available at URL: http://www.survivingsepsis.org/Pages/default.aspx

More Related