Updated: 12/19/2019

Post-Operative Fever

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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% O2
  • Cooling
  • 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
  • Incentivespirometryand 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
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(M2.ID.17.4799) A 56-year-old woman is one week status post abdominal hysterectomy when she develops a fever of 101.4°F (38.6°C). Her past medical history is significant for type II diabetes mellitus and a prior history of alcohol abuse. The operative report and intraoperative cystoscopy indicate that the surgery was uncomplicated. The nurse reports that since the surgery, the patient has also complained of worsening lower abdominal pain. She has given the patient the appropriate pain medications with little improvement. The patient has tolerated an oral diet well and denies nausea, vomiting, or abdominal distension. Her blood pressure is 110/62 mmHg, pulse is 122/min, and respirations are 14/min. Since being given 1000 mL of intravenous fluids yesterday, the patient has excreted 800 mL of urine. On physical exam, she is uncomfortable, shivering, and sweating. The surgical site is intact, but the surrounding skin appears red. No drainage is appreciated. The abdominal examination reveals tenderness to palpation and hypoactive bowel sounds. Labs and a clean catch urine specimen are obtained as shown below:


Leukocyte count and differential:
Leukocyte count: 18,000/mm^3
Segmented neutrophils: 80%
Bands: 10%
Eosinophils: 1%
Basophils: < 1%
Lymphocytes: 5%
Monocytes: 4%
Platelet count: 300,000/mm^3

Hemoglobin: 12.5 g/dL
Hematocrit: 42%

Urine:
Epithelial cells: 15/hpf
Glucose: positive
RBC: 1/hpf
WBC: 2/hpf
Bacteria: 50 cfu/mL
Ketones: none
Nitrites: negative
Leukocyte esterase: negative

Which of the following is most likely the cause of this patient’s symptoms?

QID: 109332
1

Alcohol withdrawal

2%

(1/41)

2

Surgical error

5%

(2/41)

3

Post-operative ileus

20%

(8/41)

4

Urinary tract infection

15%

(6/41)

5

Wound infection

51%

(21/41)

M 6 D

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