Presentation on theme: "Post Operative Fever Postoperative Fever Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart, M.D."— Presentation transcript:
Post Operative Fever Postoperative Fever Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D. Kenny DeSart, M.D.
Post Operative Fever 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
Post Operative Fever DDX: The 5 W’s 1.Wind (POD#1)Atelectasis, pneumonia 2.Water (POD#3)UTI, anastomotic leak 3.Wound (POD#5)Wound infection, abscess 4.Walking (POD#7)DVT / PE 5.Wonder-drug or What did we do?
Post Operative Fever 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
Post Operative Fever 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
Post Operative Fever 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)
Post Operative Fever 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
Post Operative Fever 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?
Post Operative Fever Case 1 What is your plan? –A. Urine culture –B. Blood, urine cultures & CXR –C. Blood, urine cultures & vancomycin –D. Observation only
Post Operative Fever 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?
Post Operative Fever Case 2 What is your diagnosis? A.Cellulitis B.Diffuse peritonitis C.Necrotizing fasciitis D.Uncomplicated post operative fever What is your plan? A.Observe B.ABC, resuscitate, IV antibiotics C.ABC, resuscitate, IV antibiotics, immediate surgical debridement This patient is in septic shock
Post Operative Fever 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?
Post Operative Fever 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
Post Operative Fever 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