Post operative fever

Post operative fever

1. POST OPERATIVE FEVER Dr. Mayur Patel

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 o F At 4 pm – more then 99.9 o F

3. TYPE OF FEVER Continuous – fever occur all over 24 hour with diff b/w max and min is less then 1 o C Eg . 1 st week of typhoid fever

4. TYPE OF FEVER Intermittent – fever occur daily but touches to normal limit once during 24 hour. Accourding 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. TYPE OF FEVER Remittent – fever occur all over 24 hour with diff b/w max and min is more then 1 o C and never touches to normal limit. Eg . 2 nd week of typhoid fever

6. TYPE OF FEVER Relapsing – period of fever followed by period of normal tempurature . Pel-ebstein fever – in hodgkins Cyclic netropenia

7. PATHOGENESIS OF FEVER

8. POST OPERATIVE FEVER Most of the time post operative fever occur within 72 hours and non-infectious. Fever that occur after 4 days of major operation is mainly caused by underlying infection

9. PHYSIOLOGY OF POSTOPERATIVE FEVER

10. 7 “W” OF POSTOPERATIVE FEVER WIND WATER WOUND WALK WONDER DRUG WITHDRAWAL WONKY GLAND

11. WIND – ATELECTASIS ATELECTASIS -  is the collapse or closure of a lung resulting in reduced or absent gas exchange. WITHIN 48 HOUR OF POSTOPERATIVE PERIOD CAUSE : Postoperative patients spend the majority of their day sitting or lying in bed, which leads to incomplete expansion and resulting atelectasis . Patients may have poor inspiratory effort due to sedation or pain and may be unable to clear the pulmonary secretions that are common following intubation and general anesthesia .

12. WIND – ATELECTASIS Signs and symptoms of atelectasis include – tachypnea , dyspnea , cough, decreased breath sounds, crackles, hypoxemia , and dependent infiltrates on chest radiography.

13. WIND – ATELECTASIS Identification and treatment of atelectasis are important in the early management of postoperative patients because rates of healthcare-associated pneumonia increase after the first 48 hours. Treatment for atelectasis increased pulmonary hygiene: deep inspiration assisted by incentive spirometry , early mobilization, chest physiotherapy, and bronchodilators.

14. RIGHT LOWER LOBE ATELECTASIS

15. WATER - UTI WITHIN 48 TO 72 HOUR Risk factors length of catheterization, unsterile placement or care of a urinary catheter , female sex, older age, history of diabetes, and history of previous UTIs.

16. WATER - UTI Many patients with UTIs are asymptomatic and do not require treatment. In these cases, treatment does not improve outcomes and can increase rates of antimicrobial resistance. Symptoms of UTI include  fever, suprapubic or flank pain, costovertebral angle tenderness, and urinary urgency

17. WATER - UTI Obtain a urinalysis and urine culture with sensitivity for patients with symptoms suggestive of a UTI. Positive results requiring treatment include…… pyuria , positive leukocyte esterase, positive urine nitrites, and bacterial culture showing more than 10  cfu / mL of the offending organism. 

18. WATER - UTI The most common causative organisms implicated in catheter-associated UTI are  E. coli  (27%),  Enterococcus   spp (15%),  Candida   spp (13%),  P. aeruginosa  (11%), and  Klebsiella   spp (11%);

19. WATER - UTI empiric treatment should be aimed at these pathogens with tailoring to specific organisms once culture data are available.  Empiric treatment while awaiting culture data is contingent upon the degree of patient illness, comorbid conditions, previous culture results, and local resistance pattern.

20. WOUND - SSI SURGICAL SITE INFECTION – Surgical site infections (SSIs) are defined by the CDC as infections that occur at or near the surgical incision within 30 days of surgery or within 90 days if prosthetic materials have been implanted. POST OPERATIVE DAY 5 TO 10 SSI is rare in first 3day except Group A streptococcal Clostridial infection

21. WOUND - SSI RISK FACTOR – older age, poor nutrition, Obesity, history of diabetes, Smoking other concomitant infections, impaired immune status, previous history of colonization

22. WOUND - SSI classified as superficial (skin and subcutaneous tissue only), deep (involving fascia and muscle), and organ/space infection

23. WOUND - SSI Collect specimens of the purulent drainage for culture because they typically are needed for microorganism identification and antimicrobial sensitivities to tailor treatment. Avoid routine culture swabs of incisions, which can be contaminated with skin flora. Patients with signs of severe illness (such as high fever, leukocytosis , or hemodynamic instability) out of proportion to skin findings may need radiographic studies, such as ultrasound or CT, to identify deep or organ/space infections.

24. WOUND - SSI The most common pathogens that cause SSI are skin flora, such as species of  Streptococcus, Staphylococcus,  and  Enterococcus

25. WALKING – DVT AND PE Postoperative patients account for 20% of all hospital-acquired deep vein thromboses (DVTs) POST OPERATIVE DAY 3 TO 5

26. WALKING – DVT AND PE Patients at high risk for developing postoperative DVT include those undergoing abdominal-pelvic surgery or lower extremity orthopedic  surgery, patients with major trauma or spinal cord injury, patients with cancer, and those who are obese

27. WALKING – DVT AND PE Patients also can have a febrile response to a pulmonary embolism (PE) without signs or symptoms of a DVT. PE can be a cause of sudden death in a postoperative patient. Patients with suspected DVT should be screened with a lower extremity Doppler ultrasound and started on therapeutic anticoagulation when clinically safe

28. WONDER DRUG Medications are the most common noninfectious cause of fever in postoperative patients Antimicrobials and heparin account for almost one-third of cases of drug-related fever in hospitalized patients. Antimicrobial – Vancomycin and beta lactams Anticonvulsant – phenytoin OCCUR AT ANY POST OPERATIVE PERIOD

29. WONDER DRUG Serotonin syndrome   is caused by medications interacting with selective serotonin reuptake inhibitors (SSRIs) resulting in increased serotonergic neurotransmission and overstimulation of central and peripheral serotonin receptors.  Signs and symptoms of serotonin syndrome include  fever, altered mental status, hyperreflexia , myoclonus , and mydriasis .

30. WONDER DRUG Malignant hyperthermia , which occurs in genetically susceptible patients when they are exposed to volatile anesthetics , causes profound calcium accumulation  intense muscle contraction  cellular hypermetabolism .  Can be delayed in onset upto 24 hours in immunocompromise pt Symptoms include muscle rigidity acid-base disturbances hyperthermia

31. WONDER DRUG Neuroleptic malignant syndrome   It is a dysautonomic condition thought to be caused by dopamine receptor blockade in the hypothalamus that Symtpoms muscle rigidity, altered mental status, and hyperthermia.  Most commonly caused by the typical neuroleptic medications it also can be caused by antiemetic medications such as metoclopramide and promethazine that are commonly used to manage postanesthesia nausea

32. WONDER DRUG Other drug mechanism Infusion site inflamation (phlebitis, sterile abscess, soft tissue reaction) amphoterecin B, erythromycin, KCL Stimulate heat production Thyroxin Limit heat dissipation Atropine, epinephrine Alter thermoregulaltion Butyrophenone tranquilizer, phenothiazide , antihistaminic , antiparkinson

33. WITHDRAWAL (ALCOHOL) Typically are mild with vague complaints insomnia, anxiety, headache, and diaphoresis.  These symptoms can easily be overlooked or misinterpreted as normal postoperative manifestations.

34. WITHDRAWAL (ALCOHOL) If patients are not identified and treated, they may develop delirium tremens. Delirium tremor mortality of up to 4%, begins about 72 hours after the last alcohol ingestion. Clinical features hyperthermia (temperature greater than 40° C), altered mental status, agitation, hallucinations, or seizures

35. WITHDRAWAL (ALCOHOL) The acute treatment aggressive high-dose benzodiazepine regimen, either diazepam or lorazepam , until symptoms resolve medications are then tapered over the next several days.

36. WONKY GLAND Two endocrinologic causes of fever in postoperative patients -   adrenal insufficiency and Thyrotoxicosis

37. WONKY GLAND Adrenal insufficiency hypotension hyponatremia hyperkalemia hypoglysemia fever Management of acute adrenal crisis a bolus dose of glucocorticoids with either dexamethasone 4 mg IV or hydrocortisone 100 mg IV + crystalloid volume + resuscitation glycemia and unexplained fever

38. WONKY GLAND Thyrotoxicosis tachycardia altered mental status hyper- or hypotension hyperthermia (greater than 40° C) Acute management of thyroid storm beta-adrenergic blockade ( propranolol 1 mg IV bolus) + thionamide ( propylthiouracil 200 mg oral) + iodine solutions.

39. Approach to post operative fever accourding to post-operative duration

40. POD 1-2 (24 to 48 hour = 1 st day fever) Mc cause – atelectasis Persistent infection Rare Transfusion reaction Thyroid crisis Malignant hyperthermia Drug fever

41. POD 3-4 (48 to 72 hour = 3 rd day fever) Infection related to indwelling device Cystitis, UTI Sinusitis Drip site infection – phlebitis DVT and PE Hematoma Gout Tissue necrosis

42. POD 5 to 8 Wound infection Intra-abdominal abscess Anastomosis leaked Rare Antibiotic induces colitis Acalculous cholecystitis