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

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Presentation on theme: "Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart, M.D."— Presentation transcript:

1 Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart, M.D.
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 This patient is in septic shock
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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