postoperative fever. one of the most common problems seen in surgical wards. ~2/3 of patients...

POSTOPERATIVE FEVER

• One of the most common problems seen in surgical wards.

• ~2/3 of patients develop some degree of fever postoperatively.

• Patient?• Surgery?• Timing?

A 58-year-old with PMHx of well-controlled hypertension, hyperlipidemia, and osteoarthritis undergoes RIH repair. The day after surgery, the patient is feeling well except for moderate surgical site pain controlled by pain medication. He received prophylactic cefazolin prior to the operation. Physical examination: normal except for tenderness of wound.VS: temperature 38.7°C (101.6°F), blood pressure 130/72 mm Hg. Laboratory results: white blood cell count 11,000/mm3.

Which of the following diagnostic studies andtreatment options do you recommend?

• A. Blood and urine cultures• B. Choice A plus chest radiography• C. Choice B and begin vancomycin• D. Observation only

FIVE W’S• Wind

• Water

• Wound• • Walking

• Wounder-Drugs

• “Wains” = Veins

WIND

• Atelactasis

• 0-48 hours

• Pain

• Chest physiotherapy

Atelectasis as a Cause of Postoperative FeverAtelectasis and Postoperative Fever: Where Is The

Clinical Evidence?• Chest. 2011 Aug;140(2):418-24. Epub 2011 Apr 28.

• Mavros MN, Velmahos GC, Falagas ME.

• The available evidence regarding the association of atelectasis and fever is scarce. We found no clinical evidence supporting the concept that atelectasis is associated with EPF. More so, there is no clear evidence that atelectasis causes fever at all. Large studies are needed to precisely evaluate the contribution of atelectasis in EPF.

• A 61-year-old woman with rheumatoid arthritis (medications: methotrexate and hydroxychloroquine) who is otherwise in generally good health undergoes a left total hip replacement. A Foley catheter is placed during surgery. Following surgery, she is sent to the regular orthopedic unit, where she begins to ambulate the day following surgery. A fever of 38.1°C (100.6°F) is noted on the first postoperative day. Her Foley catheter is removed on postoperative day 2. Her temperature is normal on postoperative days 2 and 3, but on postoperative day 4, her temperature is 38.5°C (101.3°F).What is the most likely cause of her fever now?A. Joint hemarthrosisB. Urinary tract infectionC. Superficial wound infectionD. Prosthesis infection

WATER

• UTI

• Especially in a patient who has had urinary catheterization.

• Day 3

• UA, UCx

WOUND

• Usually POD 3-5.

• Except ____+____ POD1-2.

• Management?

• 65y F w/ obesity, DM now 5hrs s/p open cholecystectomy for gangrenous cholecystitis c/o abdominal pain. Temp 40C, tachycardia.

• VS: HR 140, BP 88/50, O2 Sat 94%• PE: wound is blistered, +crepitus, w/ dirty

dishwater drainage

• What is your diagnosis?• What is your plan?

• What is your diagnosis?A. CellulitisB. Diffuse peritonitisC. Necrotizing fasciitisD. Uncomplicated post operative fever

• What is your plan?A. ObserveB. ABC, resuscitate, IV antibioticsC. ABC, resuscitate, IV antibiotics, immediate surgical

debridement

“WALKING”

• DVT/PE (usually 7-10d)

• Virchow’s Triad

• Risk Factors?

• Prevention: Mechanical, Anticoagulation

• Dx?

Drug Fever

• Any time.

• Antimicrobials, heparin.

• Implanted materials.

Drug Fever

Superficial Thrombophlebitis/Line Sepsis

• Any time, but usually after the catheter has been present for at least 3 days.

• Must be checked routinely.

• Mx?

APPROACH

• Hx

• P/E

• Investigations??