postoperative pyrexia

8/6/2019 Postoperative Pyrexia

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Z AAT I L I F F AH AS M AW I

POSTOPERATIVE

PYREXIA



OUTLINE

� Introduction

� Differential diagnosis for postoperative

pyrexia� Initial assessment and work up

� Management of postoperative pyrexia

� Conclusion



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



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




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




� 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



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



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



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



DAY 3 ² 5

� UTI

� Higher incidence infemales and

prolongedcatheterisation

(Foley)

� IVL infection

� Cellulitis @thrombophlebitis of

peripheral lines

� Bloodstreaminfection if centralline



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



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



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



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



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



� 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



� 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



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



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



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



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.



THANK YOU!

ANY QUEST IONS? NO? GOOD!

postoperative pyrexia

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