Post op fever

all about post op fever

1. POST OPERATIVE FEVER DR.INDUMATHI B

2. FEVER Fever is an elevation of body temperature that exceeds the normal daily variation and occur in conjunction with an increase in hypothalamic set point. At 6 am – more then 98.9 deg F At 4 pm – more then 99.9 deg F

3. TYPES OF FEVER Continuous fever- fever occur all over 24 hour with difference between max and min > 1 deg celsius . Eg . 1st week of typhoid fever

4. TYPES OF FEVER Intermittent fever -occur daily but touches to normal limit once during 24 hour. According to pattern they can be: Quatidian – fever every 24 hour (P. Falciparum, TB, UTI) Tertian – fever every 48 hour (P. Vivax ) Quartan – fever every 72 hour (P. Malaria)

5. TYPES OF FEVER Remittent fever - occur all over 24 hour with difference between max and min is more than 1 deg C and never touches to normal limit. Eg . 2nd week of typhoid fever Relapsing – period of fever followed by period of normal tempurature . Eg . Pel-ebstein fever – hodgkins Cyclic netropenia

6. Post operative fever Post-operative fever is defined as a temperature > 38 .3deg C (or greater than 101.4 deg F ) on 2 consecutive post-operative days or greater than 39 deg C (or greater than 102.2 deg F) on any postoperative day. Most of the time post operative fever occur within 72 hours- noninfectious. Fever that occur after 96 hrs after surgery - infection

7. Pathophysiology of post op fever Tissue damage and inflammation Activation of macrophage,endothelial cell & RES Release of IL-1,IL-6,TNF-alpha,IFN-gamma Act on preoptic nucleus of hypothalamus Release of prostaglandins Increase in hypothalamic set point

8. POD 1 TO 3 Atelectasis- Collapse of the lung resulting in imbalance in gas exchange. Due to hypoventilation in GA or decreased diaphragmatic movement due to surgical site pain. Fever, tachypnea , tachycardia, dull on percussion over affected area and decreased breath sounds.

9. POD 1 TO 3 INVESTIGAIONS: CXR- PA and lateral views -opacity over affected area - compensatory translucency. ABG & Helical CT chest.

10. POD 1 TO 3 TREATMENT: Adequate pain control E arly ambulation Incentive spirometry for prophylaxis Chest physiotherapy S emi-recumbent position No need for antibiotics Non invasive + ve pressure ventilation like CPAP or BiPAP

11. POD-3 Unresolved atelectasis results in pneumonia. Pneumonia is an inflammation of the lung tissue as a result of bacterial, viral or other infection . Presents with f ever, Tachypnea Tachycardia C yanosis in severe cases D ecreased breath sounds Rhonchi D ullness on percussion.

12. POD-3 INVESTIGATIONS: CXR- opacity over affected area Sputum- Culture and Sensitivity ABG, CBC, CRP

13. POD-3 TREATMENT: Broadspectrum antibiotics according to culture& sensitivity. No role for spirometry Empirically anti Pseudomonas antibiotics like Ceftazidime , Piperacillin - tazobactum Imipenum , meropenum Etc Anti MRSA antibiotics like Vancomycin & Linazolid

14. POD 3 TO 5 Catheter associated-UTI . A major predisposing factor is the presence of a urinary catheter. R isk increases with increased duration of catheterization (> 2 days ). E ffective prevention - avoidance or brief duration of catheterization ( e.g.48hours for elective surgery patients) U se of silver alloy–coated catheters when instrumentation is required.

15. POD 3 TO 5 The most common causative organisms implicated in catheter-associated UTI are E. coli (27 %) Enterococcus spp (15 %) Candida spp (13 %) P . aeruginosa (11 %) Klebsiella spp (11 %)

16. POD 3 TO 5 Signs and Symptoms: Dysuria Urgency Pelvic or flank pain Fever or chills. U rine specimen should be evaluated by direct microscopy , Gram stain, and quantitative culture The specimen should be aspirated from the catheter sampling port after disinfection of the port with 70% to 90% alcohol, not collected from the drainage bag.

17. POD 3 TO 5 Urinalysis showing more than 10*5 (CFU )/mL in a non catheterized patient more than 10*3 CFU/mL in a catheterized patient indicates UTI. Urine Leukocyte esterase & nitrites are surrogate markers for WBCs in the urine . C andiduria accounts for approximately 10% of nosocomial UTIs.

18. POD 3 TO 5 Empirical broad-spectrum antibiotics are started because most offending organisms exhibit resistance to several antibiotics and then tailored according to culture and sensitivity results . Patients with candiduria are managed with IV Flucanazole

19. POD 3-7 Surgical Site Infection: Clean -affect only skin structures & other soft tissues. Clean-contaminated –open a hollow viscus under controlled circumstances Contaminated -introduce a large inoculum of bacteria into a normally sterile body cavity for infection to become established during surgery Dirty procedures are those performed to control established infection

20. POD 3-7 SSI -nature of the procedure L ocation of the incision B ody cavity or hollow viscus is entered during surgery.

21. Risk Factors for the Development of Surgical Site Infections Patient Factors I ncreased age , Obesity Malnutrition Diabetes mellitus Hypocholesterolemia

22. Risk Factors for the Development of Surgical Site Infections Independent risk factors include: Ascites D iabetes mellitus Postoperative anemia R ecent weight loss

23. Surgical Site Infection Mild intraoperative hypothermia is associated with an increased incidence of SSIs. P erioperative oxygen administration is beneficial for the prevention of infection. Oxygen has been postulated to have a direct antibacterial effect. Skin closure of a contaminated or dirty incision increases the risk of SSIs.

24. Surgical Site Infection Drains placed in incisions cause more infections Epithelialization of the wound is prevented D rain becomes a conduit, holding open a portal for invasion by pathogens colonizing the skin. Intraoperative topical antibiotics can minimize the risk of SSIs. S igns and symptoms depend on the depth of infection

25. Surgical Site Infection Clinical signs –local induration ,erythema, edema , tenderness, warmth, pain-relate immobility-manifested before wound drainage . D eep incisional SSIs-tenderness may extend beyond the margin of erythema.

26. Surgical Site Infection With ongoing infection, signs of systemic inflammatory response syndrome such as: Body temperature >= 38 C or <36 C Heart rate >90 beats/min Respirations >20/min or Pa CO2 <32 mm Hg White blood cell count >12.0 * 10 9 /L or < 4.0* 10 9 /L

27. Surgical Site Infection Cultures are not mandatory for the management of superficial incisional SSIs . Drainage and wound care alone is sufficient without antibiotics. D eeper infection - exudates or drainage specimens should be sent for analysis from the surgically opened wound.

28. Surgical Site Infection T reatment of SSIs: Open & to examine the suspicious portion of the incision and to decide about further surgical treatment. I nfection confined to the skin & superficial underlying subcutaneous tissue- open the incision and provide local wound care .

29. Surgical Site Infection Antibiotic therapy of superficial incisional SSIs indicated -erythema extending beyond the wound margin or systemic signs of infection . Deeper SSIs may require formal surgical exploration and débridement . Organ or space SSIs occur within a body cavity a are directly related to a surgical procedure.

30. Surgical Site Infection Vacuum-assisted wound closure: O ptimizes blood flow D ecreases edema A spirates accumulated fluid facilitates bacterial clearance . Negative pressure promotes wound contraction to cover the defect And trigger intracellular signaling that increases cellular proliferation . S ternal infections after cardiac surgery, abdominal wall dehiscence, management of complex perineal wounds, or securing skin grafts.

31. Surgical Care Improvement Project Performance Measures Antibiotic Prophylaxis Glucose Control Hair Removal Normothermia

32. Antibiotic Prophylaxis P atients who have their antibiotic dose initiated within 1 hour before surgical incision P atients who receive an approved antibiotic agent for prophylaxis consistent with current recommendations P atients whose prophylactic antibiotics were discontinued within 24 hours of the surgery end time) Clindamycin use is preferred for patients allergic to β-lactam antibiotics. Vancomycin is allowed for prophylaxis of cardiac, vascular, and orthopedic surgery if there is a physician-documented reason in the medical record or documented β- lactam allergy.

33. Glucose Control Blood glucose concentration must be maintained <200 mg/ dL for the first 2 days after surgery. Blood glucose determination closest to 6 AM on postoperative days 1 and 2 is monitored.

34. Surgical Care Improvement Project Performance Measures Hair Removal No hair removal should be performed if hair is removed- clippers or a depilatory agent should be used immediately before surgery . Normothermia (Colorectal Surgery Patients) Core body temperature should be between 96.8° F and 100.4° F within the first hour after leaving the operating room.

35. POD5-7 M ost common cause of fever on postoperative day 6 is DVT. DVT is often related to venous stasis from immobility in the perioperative period. The deep veins of the lower limbs and pelvis are the most commonly affected . A palpable indurated, cordlike subcutaneous venous segment -Superficial thrombophelebitis .

36. POD5-7 M ost common sign is limb swelling. T enderness,pain , and erythema. Homan’s sign - pain in the calf upon dorsiflexion of the ankle.

37. POD5-7 R isk factors: P rior hx of DVT Obesity Immobility P elvic and orthopedic procedures C ancer H ypercoagulable state P eripheral venous disease.

38. POD5-7

39. POD5-7 TREATMENT: FH(LMWH) like fondaparinux & UFH(Heparin ) should be given for 5 days and then should be followed by oral anticoagulation with warfarin. C ontraindications to anticoagulation - IVC filter.

40. POST OP FEVER Immediate Fever occurs immediately after surgery or within hours on postoperative days (POD) 0 or 1 Malignant hyperthermia Bacteremia Gas gangrene of the wound Febrile non- hemolytic transfusion reaction.

41. POST OP FEVER Acute  Fever -Fever occurs in the first week (1 to 7 POD. Subacute   Fever - Fever occurs between postoperative weeks 1 and 4. Delayed Fever -Fever after more than 4 weeks

42. POST OP FEVER Evaluation Airway, Breathing, Circulatory, Disability, Exposure monitor vital signs . H ypotensive,-venous blood gas to measure serum lactate . Tachycardic -bedside ECG - rhythm , might rule out myocardial infarction M onitor blood glucose levels U rinalysis

43. POST OP FEVER Blood tests: WBC , CRP, hemoglobin level,  liver function tests,  coagulation parameters, platelets,RFT,serum electrolytes. Cultures - blood , urine, wound, and sputum. Chest x-ray ,ultrasound , CT scan . Venous doppler of the legs

44. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Penicillin: Gram-positive pathogens-streptococci , clostridia and some of the staphylococci that do not produce -lactamase . E ffective against Actinomyces , S preading streptococcal infections . All serious infections, e.g. gas gangrene, require highdose intravenous benzylpenicillin .

45. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Flucloxacillin L actamase-resistant penicillin T reating infections with penicillinase producing staphylococci-resistant to benzy penicillin. Good penetrating property Used in soft tissue infections & osteomyelitis.

46. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Ampicillin and amoxicillin Beta lactam penicillins can be taken orally or parenterally . E ffective against Enterobacteriaceae , Enterococcus faecalis and the majority of group D streptococci, Clavulanic acid has no antibacterial activity itself - inactivates beta lactamse .

47. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Piperacillin and ticarcillin : Ureidopenicillins with broad spectrum of activity. Used in combination with beta lactamase inhibitors( tazobactam with piperacillin & clavulanic acid with ticarcillin ) Used in the treatment of septicemia,hospital acquired pneumonia & complex UTIs. Active against pesudomonas and proteus species.

48. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Cephalosporins : cefuroxime, cefotaxime and ceftazidime are widely used . M ost effective in intra-abdominal skin and soft-tissue infections. A ctive against Staphylococcus aureus & Enterobacteriaceae . C ombined with an aminoglycoside , such as gentamicin, and metronidazole , if anaerobic cover is needed.

49. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Aminoglycosides Gentamicin and tobramycin are effective against Gram-negative Enterobacteriaceae . All aminoglycosides are inactive against anaerobes and streptococci . Serum levels immediately before and 1 hour after IM must be taken,48 hours after the start of therapy. Ototoxicity and nephrotoxicity may follow sustained high toxic levels. M arked post-antibiotic effect single, large doses are effective & safer .

50. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Vancomycin and teicoplanin : G lycopeptide -active against Gram-positive aerobic& anerobic . E ffective against MRSA O totoxic and Nephrotoxic , so serum levels should be monitored. It is effective against C. difficile in cases of pseudomembranous colitis .

51. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Carbapenems : Meropenem , ertapenem and imipenem are members of the carbapenems . stable to beta lactamase. H ave broadspectrum anaerobic as well as Gram-positive activity E ffective for the treatment of resistant organisms, such as ESBLresistant UTIS or serious mixed-spectrum abdominal infections (peritonitis).

52. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Metronidazole: W idely used member of the imidazole Group A ctive against all anaerobic bacteria S afe and may be administered orally, rectally or intravenously. Infections caused by anaerobic cocci and strains of Bacteroides and clostridia can be treated, or prevented. Metronidazole is useful for the prophylaxis and treatment of anaerobic infections after abdominal, colorectal and pelvic surgery .

53. ANTIBIOTICS USED IN TREATMENT AND PROPHYLAXIS OF SURGICAL INFECTION Ciprofloxacin: B road spectrum activity Effective against Pseuomonas infection W idespread use has been related to the development of resistant organisms, and their role in treating surgical infection is limited.

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55. references 1. Postoperative Fever Authors Tony A. Abdelmaseeh 1 ; Tony I. Oliver 2 . Affiliations- 1  Lincoln Medical & 2  University Of South Dakota. 2. Fever in the Postoperative Patient Mayur Narayan, MD, MPH, MBAa,b ,*, Sandra P. Medinilla , MD, MPHc 3.Sabiston text book of surgery ,chapter 11,pg 241-280 4.Bailey and love chapter5 pg 42

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