Snapshot A 42-year-old male underwent a Heller myotomy with subsequent Toupet partial fundoplication via a laparoscopy. The surgery was uneventful, and the patient is doing well on the floor. However, on the third post-operative day, the nurse has noted the patient has a fever or 101.5°F. The patient has been using his incentive spirometer as instructed. Vital signs are only significant for the fever. Labs show a WBC count of 12,300/mm3. Heart and lungs are clear to auscultation, and the surgical port sites are clean, dry, and intact. Abdomen is soft and nontender. There is mild suprapubic discomfort. Urinalysis shows a bacterial count >100,000 cfu/mL and a WBC of 11 cells/microL. The appropriate antibiotic therapy and catheter management was initiated. Introduction Fever > 100.4°F (38°C) may be due to infectious or noninfectious causes infectious examples: surgical site infection, urinary tract infections, pneumonia, catheter-associated infections noninfectious examples: malignant hyperthermia, medications, deep venous thrombosis In most cases, post-operative fever self resolves without treatment however, post-operative fever could be the result of a serious infection; therefore, patient evaluation is imperative Pathophysiology Stimuli → cytokine release → development of fever stimuli examples tissue trauma degree of trauma correlates with degree of fever response endotoxins or exotoxins from bacteria cytokines associated with fever: IL-6, IL-1, TNFα, INFγ Presentation and Management Possible cause of fever based on post-operative days (POD) "Wind, Water, Walking, Wound, Weird" 0 = intraoperative POD 0 1-2 3 5 7 8 - 14 Keyword Wind Water Walking Wound Weird - what do we do Etiology Malignant hyperthermia Febrile nonhemolytic transfusion (within 1-6 hours of blood transfusion) Atelectasis Pneumonia Urinary tract infection Deep venous thrombosis Pulmonary Embolism Wound infection Cellulitis Abscess Medications Management Discontinue offending agent Administer dantrolene High flow 100% O2Cooling Obtain chest radiograph and sputum cultures Empiric antibiotics if you suspect pneumonia (e.g., vancomycin for MRSA, cefepime, ceftazidime, or pipercillin-tazobactam for gram negative rods) Obtain urinalysis and urine culture Treat with appropriate antibiotics Doppler ultrasonography to detect thrombus in extremitis Heparain with bridge to warfarin Appropriate antibiotics Drainage Prevention Assess for personal or family history of malignant hyperthermia Incentivespirometry and getting out of bed may help prevent pulmonary complications Remove catheter if not necessary Pneumatic compression if low risk for DVT LMWH if moderate or high risk for DVT should determine if patient is at risk for major bleeding Sterile surgical preparation Clean wound