POSTOPERATIVE FEVER

POSTOPERATIVE FEVER

1. POSTOPERATIVE FEVER Dr. Alok Kumar Sinha

2. Definition: Temperature higher than 38C (100.4F) on two consecutive post operated day or higher than 39 c (>102.2F) on any post op day

3. Pathophysiology Fever 38 c is common after surgery usually inflammatory stimulus of surgery: resolve spontaneously fever= Response to cytokine release: not necessarily signal infection *Cytokines produced by monocyte, macrophage, endothelial cells *Associated cytokines = IL1, IL6, TNF alpha, INF gamma.

4. SIRS Four Criteria: - temperature > 38 c or <36 c - heart rate >90 -Respiratory rate > 20 - WBC - 12*10/L or < 4*10/L Sign of Organ dysfunction: -systolic BP <90 mm Hg(MAP, 65 mm Hg - drop in B.P > 40 mm Hg in hypertensive patient - lactate >2 mmol/ L -urine output <0.5 ml/kg/hr. for consecutive 2 hr. - Drop in GCS

5. Immediate Fever: 0 or 1Day Malignant Hyperthermia (40 C)- inhalational anesthetic or muscle relaxant (Halothane or Succinylcholine) Bacteremia - >40 C occurring 30 - 40 min after procedure for UTI Gas gangrene - >40 C after GI surgery due to contamination (CL. Perfringes) Febrile non hemolytic transfusion reaction

6. Acute fever POD 1 to 3 - pyretic response to surgery POD 3 - unresolved atelectasis resulting pneumonia POD 5 - Thrombophlebitis POD 7 - Pulmonary embolism POD 7 (5 - 10) Wound infection)

7. Narayan M, Medinilla SP. Fever in the postoperative patient. Emerg Med Clin North Am. 2013 Nov;

8. Subacute fever - 1 to 4 weeks POD 10: Deep infection ( pelvic and abdominal abscess)

9. Delayed fever More than 4 weeks Skin and soft tissue infection Viral infection

10. Evaluation ABCs Resuscitate History of present illness: analgesia record, operative note, nursing report, flowchart PE: - complete exam -look wounds- take off dressing - look at drain output - check peripheral IV line sites, central venous line, foley, tubes

11. Lab Studies labs to order if concerned for infection: - CBC, sputum Cx, UCx, Blood Cx . imaging: -CXR (for pneumonia) -Venous Duplex USG (for DVT) - CT scan for abscess, leak, pancreatitis, PE

12. Lab studies The risk of bacteraemia in patients with postoperative fever but no other symptoms of infection is low. Routine procurement of blood cultures in such patients is ineffective and of limited utility.

13. Management intervention needed ? remove / replace source of infection- debride wound’ remove Foley Anticoagulant for DVT/PE CT guided drainage of abscess

14. Treatment O2 fluid balance, IV fluid antibiotics Drugs - antibiotics, analgesics, antiemetics incentive spirometry venous thromboembolism

15. Differential Diagnosis pneumonia pulmonary embolism wound infection UTI transfusion reaction sinusitis

16. Take home: fever is no proof of SSI/remote infection Uçkay et al evaluated 1,071 patients for postorthopaedic fever, infection, and antibiotic use in a heterogeneous population of orthopaedic patients. Concluded that Fever as a general hallmark of inflammation despite antipyretics: 19%, A quarter of all febrile were febrile exclusively during the first 2 postop days. The majority had occasional temperature peaks for up to 1 week postop. Stratified daily temperature was similar between infected/uninfected/on prolonged antibiotic/ no antibiotics

17. Take home Occurrence of postoperative fever does not seem to be related to a worse outcome, (as reported in a prospective trial 2,311 immune suppressed patients with colorectal cancer). Chen JS, Changchien CR, Tang R (2008) Postoperative fever and survival in patients after open resection for colorectal cancer