postoperative pyrexia
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8/6/2019 Postoperative Pyrexia
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Z AAT I L I F F AH AS M AW I
POSTOPERATIVE
PYREXIA
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OUTLINE
� Introduction
� Differential diagnosis for postoperative
pyrexia� Initial assessment and work up
� Management of postoperative pyrexia
� Conclusion
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PATHOPHYSIOLOGY
IL-1, IL-6, TNF-, INF- (levels correlate withmagnitude of fever) ant hypothalamusendothelium production of PGE2 andcAMP mediate febrile response throughconservation + production of heat
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CAUSES OF POSTOP PYREXIA
5 W·s
Day 1 ² 2 Wind ² aspiration, atelectasis, pneumonia
Day 3 ² 5 Water ² UTI
Day 4 ² 6 Walking ² DVT, PE
Day 5 ² 7 Wound ² SSI
Day 7 + Wonder drugs
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CAUSES OF POSTOP PYREXIA
CommonSuperficial thrombophlebitis
Abdominal abscess
Foreign body infectionCatheter-related IV infection
Sepsis
Pneumonia
Haematoma
DVTPulmonary embolism
UncommonAcute gout
Necrotising fasciitis
Acalculous cholecystitisSeroma
Alcohol withdrawal
Malignant hyperthermia
Fat embolism
Myocardial infarctionPancreatitis
Underlying malignancy
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CAUSES OF POSTOP PYREXIA
� 5W·s as rough guide
� What can kill this patient if I miss the
diagnosis?� Early fever not infectious except nec fasciitis
� Fever � day 5: ~ 90% infectious
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FIRST 48 HOURS
� Pyrexial response totissue injury� The more traumatic
the surgery, thehigher the risk ofpostop fever
� Resolves within 2-3/7
�
Alcohol withdrawal� + altered mental
state
� Transfusion reaction@ allergic reaction� Rash, pain, shock
� Pre-existinginfection� E.g. CAP
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FIRST 48 HOURS
� Necrotising fasciitis� Group A haemolytic
strep ± Staph aureus
� Up to 70% mortality,higher if premorbidfactors and latepresentation
� Malignanthyperthermia� Autosomal dominant
� Reaction to GA drugs(succinylcholine,volatile agents
� Hypercatabolic state:T°, HR, RR, CO2, O2consumption,acidosis,rhabdomyolysis
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DAY 1 ² 2
� Atelectasis
� No consensus
� GA increasedsecretions, reduced
cough, being on aventilator
� Supine position
� Incisional pain
reduced breathing +cough effort
� Aspiration
� GA
� Immobility
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DAY 3 ² 5
� UTI
� Higher incidence infemales and
prolongedcatheterisation
(Foley)
� IVL infection
� Cellulitis @thrombophlebitis of
peripheral lines
� Bloodstreaminfection if centralline
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DAY 3 ² 5
� Other infections
� Bronchopneumonia,esp in pts with
underlying CLD,chest surgery, mech
ventilation
� Intraabdominal
infection, esp after abdominal @ pelvic
surgery ² subphrenic+ pelvic abscess
� Sinusitis if prolongedNG tube
� Foreign body
infection (prostheses,grafts, stents), usuallyStaph aureus
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DAY 5 ² 7
� VTE� DVT higher in higher in
pelvic, orthopaedicand general surgery
than head+neck surgery� in older, obese,
immobile, underlyingmalignancy
� Anastomotic leakageor breakdown� new abdominal pain,
distension, peritonism,
hypotension,tachycardia, fistula
� small leaks common,cause small localisedabscesses + delayedrecovery of bowel
function resolves withIV fluids and delayedoral intake
� major breakdown
generalised peritonitisand progressive sepsis
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DAY 7 +
� Drugs
� Antibiotics: penicillins,cephalosporins,
sulfonamides,vancomycin, rifampicin
� Diuretics: thiazide,furosemide,
spironolactone
� Anticonvulsants:phenytoin
� Others: salicylate,NSAID, allopurinol, PTU
� SSI
� Type + length ofsurgery, prophylactic
antibiotics, condition ofpatient, co-existing
diseases
� risk in diabetes,
obesity, length of
preoperative stay
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DAY 7 +
� Wound dehiscence
� Esp midline laparotomy
� Mortality up to 30%
� d/t infection, poor healing (malnourished, elderly,immuno-compromised), poor suturing technique
� Serous discharge ² protrusion of bowel loops
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HOW TO APPROACH THE PATIENTWITH POSTOPERATIVE FEVER
� History� Current symptoms: pain, SOB/cough, PU+BO
� Pre-operative course: underlying conditions
(malignancy, immunosuppression), mobility� Details of surgical procedure: emergency @ elective,
duration, site, nature of foreign body (prostheses,implants, stents etc), prophylactic antibiotics, bloodproducts + drugs administered, complications
� Previous use of tobacco, alcohol, IVD
� History of pyrexia related to surgery @ family hx ofmalignant hyperthermia
� Prior transfusions, drug hypersensitivities/allergies
� Nursing: sputum, diarrhoea, skin rash/breakdown
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� Examination (top to toe)� Vital signs including T°: rectal or oral, but consistent site
� High + swinging in pus collection (abscess, empyema)
� Low + grumbling in thrombophlebitis, DVT, atelectasis
� Mental state
� NG tube� Lungs
� CVS: tachycardia, new murmur
� IV lines
� Surgical site: inflammation, tenderness, wound + sutures, drains�
Abdomen: distension, tenderness, BS� Urinary catheter
� Skin: rashes, haematoma
� Joints: inflammation� Lower limbs: inflammation, tenderness
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� Investigations� Should be used sparingly and only as directed by the history
and physical examination� Laboratory
�
UFEME� Urine C+S, sputum C+S, wound swab C+S� FBC, LFT, D-dimer, ABG
� Blood culture if high clinical suspicion @ high risk patients: septic-looking, immunocompromised, central line, obvious woundinfection
� Septic work up if cause unclear
�
Radiological� CXR (atelectasis, pneumonia, leakage)
� Abdominal US, Doppler US
� CT scan, e.g. abdomen if recent intra-abdominal surgery andsuspect collection
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MANAGEMENT (GENERAL)
� Prophylaxis: optimise pt pre-op (DM, HPT, lungfunction), prophylactic antibiotics, aseptic/steriletechniques of procedures (even cannulation!), DVTprophylaxis in high risk pts
� ABC and resuscitation
� Antipyretic to reduce fever and decreasediscomfort
� Remove/stop unnecessary/harmful treatment and
lines/catheters� Antibiotics: withhold if patient well until known
cause, empirical if suspect infection + patientunwell taper to C+S results
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SPECIFICMANAGEMENT
� Atelectasis: pain control, incentive spirometry +chest physio, mobilisation
� Necrotising fasciitis: IV antibiotics (penicillin,metronidazole, ceftriaxone), surgical debridement
� Malignant hyperthermia
� IV dantrolene (muscle relaxant)
� discontinuation of triggering agents, supportive therapy tocorrect hyperthermia, acidosis, organ dysfunction
� UTI: remove catheter, antibiotics
�
VTE: heparin, warfarin
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SPECIFICMANAGEMENT
� SSI: open drainage, antibiotics
� Anastomotic leakage: IV antibiotics, surgery, ICU,nutrition if enteric fistula
� Intraabdominal collection: drainage (radiology-guided, surgically if inaccessible), IV antibiotics,analgesia
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CONCLUSION
� Postoperative fever should alert caregiver topossibility of infection complicating recovery, butpresence of fever not reliable indicator infectionand absence of fever does not guarantee that thepatient is infection-free.
� Non-infective causes have a better outlook thaninfective causes. The outcome for the infectedpatient is dependent on the rapid identification of
the cause, appropriate resuscitation, antibiotictreatment and appropriate surgery to eliminate thesource.
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THANK YOU!
ANY QUEST IONS? NO? GOOD!
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