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Updated: Oct 31 2021

Post-Operative Fever

  • 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
        •  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
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