DISCUSS THE

MANAGEMENT OF POST
OPERATIVE PYREXIA.
PRESENTER:DR UMAR H.S
MODERATOR:DR L.M.D
YUSUF

OUTLINE
INTRODUCTION
CLASSIFICATION
AETIOPATHOGENESIS
MANAGEMENT:
1. RESUSCITATION
2. HISTORY
3. EXAMINATION
4. INVESTIGATION
5. TREATMENT
6. CONCLUSION

INTRODUCTION
DEFINITION: Post-op pyrexia is defined as a rise
of the normal core temperature of an
individual that exceeds the normal daily
variations and in connection wt an increased in
the hypothalamic set point following surgery.
Temperatures exceeding 38c & >48hrs are
clinically significant.
Post-op pyrexia common problem after surgery.
Occur in 27-58% of surgeries in the 1 st 24 hrs.
Incidence of infection is less than 10%

CLINICAL SCENARIO
A 58yr old male. Day 1 post rt
hemicolectomy .BP/HR stable.T-38.7C.wcc 11
RX Options:
1. Urine and blood culture.
2. Above and CXR
3. 1 &2 + i.v ABTs
4. Call Registrar
5. Give PCM.
ANS:5
NB:Antimalarials in endemic areas

CLASSIFICATION
Infective :Surgical & non Surgical
Non- infective :atelectasis, drugs,
DVT ,malignant hyperthermia(MH)
SURGICAL: wound infxn ,intra
abdominal abscess, leaking
anastomosis with sepsis, infected
prosthesis.
Non Surgical : malaria, Pn, UTI,
pharingitis, systemic bacteraemia .

AETIOLOGY
Underlying cause depend on :
1. Time since surgery(5 W).
2. Type of surgery: e.g colon resection,
cholecystectomies and laparoscopic.
3. Associated clinical features.
. 1st 24hrs :
1. Systemic response 2 surgical trauma
2. Pre-existing infxn :UTI, empyema,PID.

Pathogenesis
Regardless of whether fever is associated
with infection, or not , the thermostat is
reset in response to endogenous
pyrogens, including the cytokines
interleukin 1 (IL-1) and IL-6, tumor
necrosis factor- (TNF-), and interferon-
(IFN-) and IFN-.
Setting of body temperature & detection
of core T in d preoptic nucleus is by
Hypothalamus.

 Caused by circulating pyrogens

Pyrogens can b
Exogenous Gram-negative bacteria endotoxin
Endogenous cytokines

Culprits are TNF-, INF-, IL-1, and IL-6

IL-6 levels correlate logarithmically with postop peak body temperature
IL-1 is crucial in the febrile response to injured
tissue
TNF-, INF-, and IL-6 are pro-inflammatory

SYSTEMIC RESPONSE TO
TRAUMA
A rise in temp in the 1st 6hrs or the
following morning after a surgery
,which maximize on d 2nd day n begin
to fall, had been noted in many post
op pts. See charts.

Temperature Charts

post-op Pyrexia in surgical

trauma
Cuthberston: metabolic changes that
occur giving rise to post-op pyrexia .
Wilson: acute toxaemia wt a toxin
prdtn in damaged tissue leading to
pyrexia.
CONCLUSION: Pyrexia occur due to
either of d two or both.

24hrs-72hrs
Pulmonary atelectasis: impaired
cough reflex, hypoventilation etc
Chest infection: distruption of natural
defensive mechanisms
,hypoventilation ,intubation
,anesthetic agents.

3-7d
Wound infection :skin defence distruptd,
duration of surgery, type, and age of pt
Anastomotic leak:ischaemia.
Intra abdominal abscess; abd. &pelvic
surgeries
Intra-peritonial-sepsis: operation in septic
conditions.
UTI: prolong catheterization.
Thrombophlebitis: i.v access, damaged
endothelium.

7-10d
DVT: Veinous stasis, endothelial
damage, prolonged immobilization
Pulmonary embolism: above in big
veins + embolization into pulmonary
arteries
Prosthetic infection:
NB: malaria can occur anytime post
op in endemic areas!

Study of post-OP Pyrexia by OHANAKA

& CO Surgery department BENIN.

7O pts studied post Op ,all had G.A.

30 had fever.
11 mps +ve.
1o no surgically related cause.
9 had surgically related causes.
The 10 treated wt empirical antimalarials.
Responded well.
6 post -OP wt no fever mps +ve.
(ENDEMICITY OF MPS)

MANAGEMENT
1. RESUSCITATION:ABCD in life
threatening conditions; MH, or wt
other post op emergencies.
2. IDENTIFY SOURCE
3. ELIMINATE SOURCE.

HISTORY
Indication for surgery.
Operation details: duration of op, type of
procedure, prophylactic ABTs, blood
transfusion, intra-op complications
Pre-existing medical conditions & events
Inhospitable progress and interventions.
Previous hx of pyrexia related to surgeries, or
family hx.
Use of tobacco, alcohol.
Symptoms suggestive of above c0nditions:

SYMPTOMS AND SIGNS OF

AFFECTED SYSTEMS
Atelectesis: cough ,chest pain, .shallow
breathing. cyanosis,dim.air entry, dull P.N,
dim. air entry, rales.
Pneumonia :cough; productive chest ,
pain, breathlessness.
Wound infection: site pain, swelling,
redness, purulent discharge ,tenderness.
Anastomotic leak: pain localized or
generalized,
distention.tenderness.guarding,ileus.

continuation
UTI: dysuria, frequency ,rigors. loin
tenderness
DVT: silent 2/3rd, swelling of foot
,ankle or calf ,pain ,tender ,warmth,
superficial veins
PE: massive; collapse &death,
cyanosis, severe dyspnoea, pallor,
hypotention.

EXAMINATION
P.E: Temperature measurement, other
physical signs above related to systems
affected.
Vascular access sites;haematoma.
Drains & tubes.
Skin & subcutaneous ;abscess ,necrotizing
fascitis, gas gangrene.
Wound site:fluctuant mass, redness,
tenderness discharge.
Relevant system as suggested from history.

INVESTIGATIONS
Haematological: fbc, mps, platelets,E/U/CR,LFT,
coagulation profiles
1. wcc : leucocytosis, neutrophylia, toxic
granulation.
2. Platelets: increased in stress, decreased in DIC.
3. Hb:decresed in hypodilution.
. SERUM Biochemistry: e/u/cr deranged in severe
sepsis wt renal failure .LFT; deranged in severe
sepsis. Arterial blood gases; metabolic acidosis
e.g, septic shock. myocardial enzymes ,serum
amylasis

CONTINUATION
Microbiological: blood culture, sputum mcs,
pleural & peritoneal aspirates. wound
swabs. needle aspiration. stool mcs. csf,
catheter tips; urinary & intravascular.
Radiologic: CXR; collapsed lung field,
effusions, consolidations,subphrenic
abscess. ABD uss ;intra abdominal
abscess, ileus ,DVT .CT: Abscess .ECG &
ECHO: myocardial ischaemia, anomalies of
cardiac fxn.

TREATMENT
AIM :
1. Reduction of the elevated hypothalamic
set point
2. Fascilitate heat loss
3. Reduce oxygen demand.
4. Prevent the aggravation of cardiac,
cerebral and pulmonary insufficiencies.
5. Prevent febrile seizures in child.
6. Treating underlying causes identified.

GENERAL MEASURES
1. Antipyretics.indicated in T above 39c.Decrease
headache,myalgia &arthralgia.
2. Antibiotics:based on sensitive cultured organism
or best guess.
3. FLUIDs therapy: hypovolaemia ;septic shock
.use vol. expanders;gelatin,dextran
+crystalloids.
4. Respiratory support:oxygen therapy.
5. Ionotropes &vaso active agents:systemic
infection depress
myocardiume.g,adrenaline,dobutamine.

Surgical therpy
Abscess :open drainage.
Elimination of hollow spaces to
infections
Correction of lesion.
Excision of diseased organs:gangrene

conclusion
Post-op fever should alert the possibility of an
infectn complicating d recovery of the pt.
Presence of pyrexia is not a reliable indication of
infection and absence is not a guarantee of
infection free.
The outcome of pt wt post-op pyrexia depend
on cause.so detailed ,focused evaluation
needed.
The outcome of infected pts depend on rapid
diagnosis,appr.resuscitation and appr surgeries
wr indicated.

THANK YOU