SURGERY:

Case 38 Postoperative
Fever:
- Suprapubic pain & costovertebral tenderness are physical findings suggestive of UTI,
most likely acute pyelonephritis.
- Drug fever: fever that coincides w/ the administration of a particular drug & cannot
otherwise be explained by clinical
& laboratory findings. Resolution of the fever occurs w/ discontinuation of the suspected
drug. Drugs that are usually implicated are beta-lactams, sulfa derivatives, heparin &
amphotericin B.
- Malignant hyperthermia: a rare autosomal dominant disorder characterized by
fever of greater than 104 degrees F (40 degrees C), tachycardia, metabolic
acidosis, & calcium accumulation in skeletal muscle leading to rigidity. This may
occur up to 24 hrs after exposure to certain anesthetic agents such as halothane &
succinylcholine. Treatment includes supportive therapy, such as antipyretics,
oxygen, cooling blankets, & dantrolene IV.
- Surgical site infection (SSI):a concept introduced by the Centers for Disease
Control & Prevention (CDC) & various consensus panels to replace the term
surgical wound infection. This refers to any infection that occurs in the site of
surgery & classified as superficial, deep, or organ/space SSI.
- Fever (defined as >38.3 deg C/101.0 deg F) is the most common postop
complication, occurring in 50% of major surgery in the immediate postop period. As
an integral part of informed consent prior to surgery, pts need to be made aware by
the physician of the possibility of experiencing post op febrile episodes.
o Fortunately, postop fever typically resolves spontaneously & most of
the time does not necessarily indicate the presence of infection.
- Strategies to reduce the risk of postop fever:
o Preop interventions: optimize nutritional status, smoking cessation, treat any
existing active infections,
optimize management of existing medical conditions, reduce dosage of
immunosuppressive therapies.
o Periop interventions: administer perioperative antibiotics, use noninvasive
ventilation, if intubation necessary, use pneumonia prevention protocols,
remove catheters, IV lines, tubes, & drains as soon as safe, change lines
after 72-96 hrs if they are still needed, DVT prophylaxis using early
mobilization, sequential compression devices, subcutaneous heparin, or
lmw heparin.
- 5 Ws to remember the most common causes of postop fever in order of frequency:
o Wind (pneumonia)
o Water (UTI)
o Wound (SSI)
o Walk (DVT)
o Wonder drugs (drug fever)
- If 3 or more of the following risk factors are present, the likelihood of infection as
the source of fever approaches 100%:
o Preop trauma
o American Society of Anesthesiologists (ASA)ndscroe greater than 2 (pt w/ mild
systemic disease or worse). o Onset on the 2 postop day.
o WBC count greater than
10,000 cells/mm3 o BUN
greater than 15 mg/dL
o Systemic manifestations such as chills & rigors.
- Tissue trauma during sx stimulates an inflammatory response that leads to release
of pyrogenic cytokines from the tissues.
- There are a few causes of fever in the immediate postop period. One of them is
malignant hyperthermia, which is characterized by markedly elevated
temperature, up to 104 deg F, shortly after induction of anesthesia w/ agents
 such as halothane & succinylcholine. Another is bacteremia, which occurs more
commonly in urologic procedures that involves instrumentation. Gram-neg
bacteria are the most common pathogen.
- If fever occurs w/in 36 hrs post-laparotomy, there are 2 important infectious
etiologies to be kept in mind bowel injury w/ leakage of GI contents into the
peritoneum & invasive soft-tissue wound infection caused by beta-hemolytic strep or
Clostridium.
- W/in first 48 to 72 hrs postop, atelectasis (partial collapse of peripheral alveoli)
causes 90% of pulmonary complications of surgery. The alveolar collapse is
compounded by the loss of functional residual capacity in almost all patients, & 50%
reduction of vital capacity intraoperatively.
o W/out resolution of atelectasis, pneumonia may ensue, on the 3 rd
postoperative day, when the build up of secretons facilitates growth of
bacteria.
o Aspiration as the possible cause of pneumonia should be suspected in the
elderly, those who reside in a nursing home, & those w/ neurologic
dysphagia, altered mentation, & GERD. Gram-neg coverage is required for
aspiration pneumonia.
- The pt w/ persistent fever 5 7 dys after sx needs to have a thorough exam of the
operative site to check for signs of infection, which include erythema, pain, local
edema, & purulent discharge.
o Surgical site infection has markedly decreased through wide practice of
aseptic technique.
- Drug fevers are often associated w/ rash &/or lupus like syndromes. They also may
have renal, liver, or hematologic dysfxn associated w/ drug toxicity. Common
medications associated w/ drug fever include cephalosporins, fluoroquinolones,
sulfonamides, & penicillins.
- Purulent drainage & fluctuance indicate the presence of abscess, which requires
incision & drainage.
o Deep abscesses produce fever 10 15 dys after surgery. A high level of
suspicion leads to diagnostic imaging such as CT scan of the body region
most likely to be infected.
- IV catheter or line-associated infections needs to be entertained when the pt has had
IV devices for 3 days or more, even when the site appears clean. Any unnecessary
line should be discontinued. The catheter tip is cultured to reveal the offending
organism.
- Fever caused by DVT usually occurs on the 5 th postop day. Common complaints
are leg edema, tenderness, pain, & warmth.
o Homan sign (pain in the calf on foot dorsiflexion) is demonstrated in some
causes.
o Dx is made w/ duplex ultrasound, but most accurately confirmed w/
venography.
o Pts who develop pulmonary embolism, usually have concomitant DVT.
- Pneumonia is currently the leading cause of mortality from nonsurgical postop
nosocomial infection. Mortality rate is 20% to 50%. Mechanical ventilation is the most
important risk factor.