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Postoperative Fever

Postoperative Fever. Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart , M.D. Pathophysiology. Fever >38ºC is common after surgery Most early postoperative fever is caused by the inflammatory stimulus of surgery and resolves spontaneously Fever = response to cytokine release

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Postoperative Fever

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  1. Postoperative Fever Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart, M.D.

  2. Pathophysiology • Fever >38ºC is common after surgery • Most early postoperative fever is caused by the inflammatory stimulus of surgery and resolves spontaneously • Fever = response to cytokine release • Fever-associated cytokines are released by tissue trauma and do not necessarily signal infection • Cytokines produced by monocyte, macrophages, endothelial cells • Fever-associated cytokines = IL-1, IL-6, TNF-alpha, IFN-gamma

  3. DDX: The 5 W’s • Wind (POD#1) Atelectasis, pneumonia • Water (POD#3) UTI, anastomotic leak • Wound (POD#5) Wound infection, abscess • Walking (POD#7) DVT / PE • Wonder-drug or What did we do?

  4. DDX: Immediate Fever • Immediate fever: onset in OR or in the immediate postoperative period • Go look at the wound • DDX: • Medication reactions: antibiotics, blood products, malignant hyperthermia. Often p/w hypotension. • Necrotizing infection: Clostridium, Group A β-hemo strep. Treatment: ABC, resuscitate, ABX: pip/tazo and clindamycin, surgical debridement

  5. DDX: Fever • DDX: • Necrotizing infection (within 48hrs) • Anastomotic leak (classically POD# 3 to 5) • Pulmonary embolism • Pneumonia/Aspiration • UTI • Surgical site infection (SSI) • Deep abscess • ETOH withdrawal • Clostridium difficile colitis • CVL infection • Other: acute gout, pancreatitis

  6. Evaluation • ABCs • Resuscitate • HPI: anesthesia record, operative note, nursing report, flowchart • PE: • Complete exam • Look at wounds - take off dressings • Look at drain output • Check PIV sites, CVL, Foley, tubes

  7. Labs/Studies • Labs to order if concerned for infection: • CBC w diff, sputum Cx, UCx, Blood Cx x2 • Lumbar puncture (if AMS, neck pain, fever-rarely ordered) • C. diff toxin assay from stool • Imaging: • CXR (for pneumonia) • Lower extremity venous duplex (for DVT) • CT scan (for abscess, leak, pancreatitis, PE) • Usually wait until POD5 • RUQ ultrasound (for cholecystitis)

  8. Management • Remove/replace sources of infection • Foley catheter, central lines, or peripheral IV’s • Open, debride, and drain infected wounds • Antibiotics typically not prescribed for superficial wound infection • If suspect pneumonia, bacteremia, UTI, sepsis – start broad spectrum antibiotics • Anticoagulation for DVT/PE • CT guided drainage of abscess

  9. Case 1 • 58y M 5hrs after B/L total knee arthroplasty. Temp 38.7 C. Pain adequately controlled w/meds. No antibiotics. • PE: HR 90, BP 130/70, O2 sat: 99% • Mild serosanguinous drainage from knees • No Foley or CVL • WBC 7 • What is your plan?

  10. Case 1 • What is your plan? • A. Urine culture • B. Blood, urine cultures & CXR • C. Blood, urine cultures & vancomycin • D. Observation only

  11. Case 2 • 65y F w/ obesity, DM now 5hrs s/p open cholecystectomy for gangrenous cholecystitis c/o abdominal pain. Temp 40C, tachycardia. • VW: HR 140, BP 88/50, O2 Sat 94% • PE: AMS, wound is blistered, +crepitus, w/ dirty dishwater drainage • What is your diagnosis? • What is your plan?

  12. Case 2 • What is your diagnosis? • Cellulitis • Diffuse peritonitis • Necrotizing fasciitis • Uncomplicated post operative fever • What is your plan? • Observe • ABC, resuscitate, IV antibiotics • ABC, resuscitate, IV antibiotics, immediate surgical debridement This patient is in septic shock

  13. Case 3 • 61y F w rheumatoid arthritis on methotrexate undergoes left total hip replacement. Foley catheter present postoperatively. POD#1 temp 38.1C, Foley is removed. POD#4 temp 38.5 C. • She has been ambulating and using incentive spirometry • PE: O2 Sats and vitals are normal, wound is clean What is the diagnosis? What is the plan?

  14. Case 3 • What is the most likely diagnosis? • A. Deep venous thrombosis • B. Urinary tract infection • C. Superficial wound infection • D. Prosthesis infection • UTI evaluation: history, U/A, urine culture • Evaluate for other possibilities

  15. Take Home Points • The 5 W’s • Think the worst and rule it out! • Must correlate clinically • USE COMMON SENSE!!! • Necrotizing fasciitis must be identified and treated aggressively

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