Presentation on theme: "Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart, M.D."— Presentation transcript:
1Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart, M.D. Postoperative FeverTad Kim, M.D.Connie Lee, M.D.Michael Hong, M.D.Kenny DeSart, M.D.
2Pathophysiology Fever >38ºC is common after surgery Most early postoperative fever is caused by the inflammatory stimulus of surgery and resolves spontaneouslyFever = response to cytokine releaseFever-associated cytokines are released by tissue trauma and do not necessarily signal infectionCytokines produced by monocyte, macrophages, endothelial cellsFever-associated cytokines = IL-1, IL-6, TNF-alpha, IFN-gamma
3DDX: The 5 W’s Wind (POD#1) Atelectasis, pneumonia Water (POD#3) UTI, anastomotic leakWound (POD#5) Wound infection, abscessWalking (POD#7) DVT / PEWonder-drug or What did we do?
4DDX: Immediate FeverImmediate fever: onset in OR or in the immediate postoperative periodGo look at the woundDDX: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
6Evaluation ABCs Resuscitate HPI: anesthesia record, operative note, nursing report, flowchartPE:Complete examLook at wounds - take off dressingsLook at drain outputCheck PIV sites, CVL, Foley, tubes
7Labs/Studies Labs to order if concerned for infection: CBC w diff, sputum Cx, UCx, Blood Cx x2Lumbar puncture (if AMS, neck pain, fever-rarely ordered)C. diff toxin assay from stoolImaging:CXR (for pneumonia)Lower extremity venous duplex (for DVT)CT scan (for abscess, leak, pancreatitis, PE)Usually wait until POD5RUQ ultrasound (for cholecystitis)
8Management Remove/replace sources of infection Foley catheter, central lines, or peripheral IV’sOpen, debride, and drain infected woundsAntibiotics typically not prescribed for superficial wound infectionIf suspect pneumonia, bacteremia, UTI, sepsis – start broad spectrum antibioticsAnticoagulation for DVT/PECT guided drainage of abscess
9Case 158y 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 kneesNo Foley or CVLWBC 7What is your plan?
10Case 1 What is your plan? A. Urine culture B. Blood, urine cultures & CXRC. Blood, urine cultures & vancomycinD. Observation only
11Case 265y 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 drainageWhat is your diagnosis?What is your plan?
12This patient is in septic shock Case 2What is your diagnosis?CellulitisDiffuse peritonitisNecrotizing fasciitisUncomplicated post operative feverWhat is your plan?ObserveABC, resuscitate, IV antibioticsABC, resuscitate, IV antibiotics, immediate surgical debridementThis patient is in septic shock
13Case 361y 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 spirometryPE: O2 Sats and vitals are normal, wound is cleanWhat is the diagnosis?What is the plan?
14Case 3 What is the most likely diagnosis? A. Deep venous thrombosis B. Urinary tract infectionC. Superficial wound infectionD. Prosthesis infectionUTI evaluation: history, U/A, urine cultureEvaluate for other possibilities
15Take Home Points The 5 W’s Think the worst and rule it out! Must correlate clinicallyUSE COMMON SENSE!!!Necrotizing fasciitis must be identified and treated aggressively