post operative fever - surgeon's envy
DESCRIPTION
Fever in post-operative period is tension giving to a caring surgeon. Apart from a major surgery under general anaesthesia where transient fever may occur on first day, fever is not welcome. Therefore, try to find out the cause and treat accordingly.TRANSCRIPT
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POST OPERATIVE FEVER – SURGEON’S ENVY
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Thermoregulation
Balance between heat production and heat loss
Heat production-oxidative process
Catacholamines Thyroxin Increase in substrate load in metabolic
pathway
I/3 of Heat producing activity takes place in muscle mass-increase in muscular activity like exercise or shivering has considerable effect on heat production.
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Heat loss
Conduction & Convection
Vasodilatation(transfer of heat from core to surface)
Evaporation – sweating,most important mechanism of heat expenditure
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NORMAL BODY TEMP
Normal body temp. 36.2-37.5C(97-99° F) Diurnal variation 0.5 to 1.5 °C (0.9-2.7°F.) Low in morning hours, max in evening Hypothalamus regulates this-input from
temperatura sensitive nerve endings in viscera, skin, temp. sensitive receptors in Ant .Hypothalamus
Temp. regulatory neurons in post hypo alter sweating, by vasoconstriction, vasodilatation and hormonal regulation
Local spinal cord reflexes also regulate vasodilatation, and vasoconstriction.
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PATHOGENESIS OF FEVER
FEVER means Heat prod or Decrease heat expenditure Insufficient sweating or by vasoconstriction
Increase Heat production - Elevation of Catecholamines or thyroxin Inappropriate shivering or abnormal muscle
activity.
PYROGENS - A febrile reaction is initiated by pyrogens. May be Exogenous or Endogenous
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Classification of Fever
INTERMITTENT (Spiking) Intermittent elevation of temp with regular return to
normal (infection within closed space-abscess)
REMITTENT/FLUCTUATING Continuous type of fever drop in fever without returning to normal-brucellosis, blood stream infections, infected arterial grafts, phlebitis.
UNREMITTING/CONTINUOUSContinuous high fever-CNS injury, pneumonias, typhoidNote: Hydration, Muscle activity, sleep and medication
also alter febrile response.
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Altered Febrile Response
AGE; INFANTS HAVE A HIGH TEMP ranging as high as 40.6 OLD AGED Patients - DIMNISHED RESPONSE
MEDICATIONS- NSAID, Steroids-absence of fever
TRAUMA- Fever in trauma is bad sign, trauma to hypothalamus
disturbs thermoregulatory mechanism .
IMMUNOSUPRESSION- Altered production of endogenous leukocyte, pyrogens, lack a febrile response
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FEVER IN POST OPERATIVE PATIENT
WIND, WATER, WOUND
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FEVER IN POST OPERATIVE PATIENT WIND , WATER, WOUND COMMON CAUSES
ATELACTASIS
VENOUS THROMBOSIS
URINARY TRACT INFECTION
SURGICAL WOUND INFECTION
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DAY 1 -2 (24 – 48 HRS.)FIRST DAY FEVER
ATELACTASIS
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ATELACTASIS OR PNEUMONITIS Anesthesia agents cause increase production
of secretions, as water evaporates, they become viscous.with diminished cough reflex & decrease ciliary activity - formation of mucus plug- obstruct small airways. When the gases distal to plug get absorbed the airways collapse.
Febrile response is due to Low grade infection distal to obstructing plug and absorption of bacterial pyrogens
Temp elevation within 12 hrs of onset of plug formation.max temp is characteristically 38.9 degree centigrade
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PNEUMONITIS
High risk group - Cigarette smoking, chronic bronchitis, COPD
3% of all ORS, 15% abdomen, 25% upper abdomen
Continued atelactasis predispose to full blown Pneumonitis
Prevention: Assessment of patient, Avoid General Anaesthesia,
Stop smoking, spirometery, Assess pulmonary mechanics, Thick mucus secretions need inhalations to FOB, chest physiotherapy, early mobilization.
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THIRD DAYSURGICAL FEVER48-72HRSTEMP ELEVATION TO 40.6 TO 41.1
Phlebitis
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PHLEBITIS
IV catheter sepsis DVT and Pulmonary embolism Suppurative thrombophlebitis
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Temp elevation to 40.6-41. 1°C Tachycardia, Hypotension, Oliguria, Prostration,
Leukocytosis, Hard chills-52%develop septic shock, mortality rate 40% in 40yrs above age and 80% in above 80yrs age.
Tenderness and erythema around catheter.
Precipitating causes: Hyperosmolar infusate, K conc sols, antibiotics,
size of vein in which catheter. This can be decreased by adding one unit of heparin. IV septic technique
Cathater sepsis reduced from 23% to 4% keeping Intravenous catheter in place for max 12 hrs.
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IV catheter sepsis
Lack of aseptic technique Use of hypertonic solutions Multiple infusions through same line Change of site after 72 hrs. Early signs-Red streaks
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THIRD AND FOURTH DAY FEVER
DVT & PULMONARY EMBOLISM
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DVT & PUL. EMBOLISM
3 -4 days Temp elevation, calf Tenderness (Homan’s sign)
Doppler ultrasound, has replaces contrast venograms
Treatment is PREVENTION Identify High risk group from pre-op
stage. Start prophylactic heparin sub cut peri-
operative Mechanical means
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PULMONARY EMBOLISM
SEQUELAE OF DVT
FEVER DOES NOT APPEAR UNTIL PUL THROMBO EMBOLISATION-PAIN CHEST, DYSPNOEA,
TREATMENT IS PREVENTION
THERAPEUTIC DOSE OF HEPARIN
NEED HDU
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SUPPURATIVE THROMBOPHLEBITIS PRESENCE OF SUPPURATIVE
INFECTION IN VEIN IS OFTEN LETHAL-NEED LIGATION OF VEIN
HIGH FEVER , REMITTENT TYPE
COMMON SITES ARE; Basilic,Cephalic, Neck veins
OCCASIONALLY SEEN IN PELVIC VEINS after SEPTIC ABORTION, AND PID.
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URINARY TRACT INFECTIONS
Most common nosocomial infection (40%) 75% patients have some form of urine tract
manipulation Bacteria found in urine in 1-5% of patients
undergoing short term catheterization, 90% pts in whom Foley is left for 48hrs or more
Post op UTI; temp 39.4-40°C, rigors/chills Management –prevention, PUT Catheter only when
must, Aseptic technique , closed drainage system. Discard drainage system if accidentally disconnected and change when obstruction or contamination occurs.
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DAY 5-8 FEVERSurgical wound infection
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SURGICAL INFECTION
Wound infection‘ present as abscess-cellulites
Signs of erythema, foul discharge, indurations, soakage
Treatment is adequate drainage &/antibiotic coverage
Factors responsible-patient related , disease related, procedure related, environment related.
Lack of preventive measures.
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BENIGN POST OPERATIVE FEVER
During Operation Thermo regulatory mechanism Hypothalamus becomes inhibited by Anesthetic agents –fall in body temp, thermo neutrality with atmosphere
Once anesthesia effect is gone- recovery of this mechanism but intracranial core temp still decreased-thermosenstive receptors in hypothalamus sense decreased temp and attempt to raise body temp to hypothalic set point, often there is over compensation with a mild febrile episode in post op period
This is diagnosed by exclusion
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Other non surgical Causes….. MALARIA, BRUCELLA, TYPHOID.
MALIGNANT DISEASES
POST CARDIOTOMY FEVER SYNDROME
BLOOD TRANSFUSION
PHAYNGITIS - OTITIS
ADDISONIAN CRISIS
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OTHER CAUSES
Hyper metabolism -increased BMR in response to surgery –burn pt, returns to normal with wound healing
Drug induced Fever
DEHYDRATION-decreased sensitivity to sweating mechanism
Malignant Hyperthermia
THYROID STORM
FEVER OF CNS ORIGIN
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DRUG INDUCED FEVER
Drugs that cause fever due to effects of pharmacological activity; Antibiotics, Cytotoxic agents
Drugs causing fever due altered thermoregulation Atropine, Catacholamines, (Decrease sweating) Increased BMR- thyroxine derivatives
Drugs causing fever due to contaminants; IV solutions
Drugs that cause fever indirectly; anticoagulants
Drugs causing fever due to hypersensitivity-sulphas, penicillins,
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MANAGEMENT OF POST OP FEVER Measures/procedures to determine cause
History;onset,type, medication-blood transfusion Exam;chest, IV sites, lower limbs DVT, calf tenderness,
ENT exam, assess Hydration,
Lab work. CBC, urine routine/cs, Chest X-Ray, C/s-Throat, nasopharynx, wound, blood culture
( x2 )if temp >38.9
Culture; Drain or tube, or cath tips, iv caths Typhoid, Brucella-tests. Treat; underlying cause. Treat fever, maintain
hydration, nutrition
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SUMMARY
Fever is common and readily detectable manifestation of disease .In the post op pt the most common potentially serious causes are atelactasis or other pulmonary problems, phlebitis in deep veins or at iv sites, UTI, and surgical wound infection.
Other benign and potentially serious causes occur less commonly but must be suspected when more common causes are not found. treatment directed towards cause. Fever controlled by salicylates and by mechanical means if control is warranted,