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Fever post operative (gynaecological)
 

Fever post operative (gynaecological)

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    Fever post operative (gynaecological) Fever post operative (gynaecological) Presentation Transcript

    • Prof. M.C.Bansal. Founder Principal &controller; Jhalawar Medical College Jhalawar. Ex. Principal & Controller; Mahatma Gandhi Medical College & Hospital; Sitapura, Jaipur
    •  Definition Fever is the rise of normal core temperature of an individual that exceeds the normal diurnal variation and is accompanied by an increased hypothalamic setup.  DiurnalVariation in 18-40 years of age— MeanTemperature : 36.8+/- 0.4 C (98.2+/- 0.7 F ). ;being low at 6 AM –36.2 c or98.0 F and highest at 4-6pm in the range of 37.7 c or 98.9 F. Temperature > 38C(100.4 F )recorded at two occasions at the interval of 4hrs apart , excluding 1st 24 hrs after surgery or any one temperature recording more than 38.6 c ( 101.5 F ) is taken as post operative fever. Incidence varies widely from 14-91 % . THIS MAY BE INFECTIOUS / NONINFECTIOUS. 80-90 % patients developing temperature with in 24hrs after operation are not infected , but patients who develop fever on /5th post operative day(80-90 % ) usually have commonly identifiable infection . Infection is definite if it develops after 2days of surgery.
    •  Shivering;  Chills– may be alternate to feeling of hot;  General Malaise;  Somnolence;  Anorexia;  Arthralgia , myalgia, skin sensitivity to touch ;  Absence / presence of sweating;  Skin rash;  Increased pulse rate / BP.
    •  Time related causes described here are only guidelines and do not serve as rule. On many times there is temporal overlap in the causes described –5Ws  POD 1-2 Wind (respiratory ) atelectasis develop within 24-48 hrs . Aspiration pneumonia, ventilator associate pneumonia .  POD3-5Water—UTI, specially in catheterized patient.  POD5-6W(veins) , wings , walking –DVT , Iv cannula site plebitis , IM, injection abscess.  POD5-7 wound– check for wound infection ,drainage , alternate sutures removal , swab culture and diagnose serious problem such as necrotizing fascitis and peritonitis due to intestinal leak ( internal wound).  POD 7+ Wonder if ? Drug induced—drug reaction , drugs used intra / post operative / transfused blood or blood products , anti inflammatory agents etc.
    • Sinusitis Thyroid disorders Meningitis Seasonal infections-- Pharyingitis, Swine Flue malaria , Dangu etc. Adrenal Insifficiency Medication s Infected central catheter Pheochromocytoma **Drug Fever associated with skin rash/ eosinophilia-- Ventilator –associate Pneumonia Myocardial infarction ----Antiepileptics—phenytoin, Infected Hematoma Pulmonary Embolism --- Antibiotics beta lectum s, sulphas , piperacillin ,tezobactam. Acute gout / flare-up . Neuroleptic malignancy tumor ---Anti inflammatory drugs – Endomethacin, AcuteAlcohol withdrawal Intra cranial pathologies --- Intra operative drug – Succinyl chloride
    •  Malignant Hyperthermia  rare  dominantly transient  genetic disorder triggered by administration of succinyl chloride  occurs with in ½ an hour of its administration , but may persist for < 10 hours.  BP unstable , rise in heart rate , fever may shoot up to 41- 42 C .  Muscle rigidity , acidosis, hypoxia cardiac arrhythmia develops .  Treatment is to stop all anesthetic drugs , hyper ventilation, O2.  Initiate cooling , and diuresis to prevent precipitation of myoglobin . Inject dantrolene sodium and procainamide.
    •  Adrenal Insufficiency-Typically occurs in patient who are taking corticosteroids for a long duration ; owing to suppression of endogenous steroids (hypothalmo- pituitary –adrenal axis ). Fever , refractory fall in BP may develop . Steroid supplementation in time will resolve the problem.  Pulmonary embolism  usually presents as hemodynamic sudden post operative hemodynamic instability and collapse . Fever, although uncommon , may be present.  AlcoholWithdrawal  frequently presents with fever , prompt recognition and treatment prevents excessive morbidity and mortality.
    •  Myo necrosis –  common due to wound infection  Clostridium species or group A Strepto –cocci.  It is a surgical emergency  patient presents with shock, tachycardia, fever and septicemia with in 24 hours after operation.  Di9agnosis is easy if dressing is opened and wound is examined . Thin brownish copious malodorous discharge is present .Take swab for culture and sensitivity.  Skin may be discolored , subcutaneous crepitations , bullae formation .Patient has severe pain, restlessness and local tenderness. If not treated immediately patient may have vascular collapse, acute renal failure , haemoglobinuria and jaundice.  Wide excision of all infected and necrosed tissue , high dose of C. penicillin 20 lacs 6hrly after AST / tetracyclines is mandatory.  D/D – metastastic Myonecrosis from adeno carcinoma of bowel
    •  Necrotizing Fascitis  occurs due to wound infection by poly microbes– haemolytic strepto cocci, staphylococcis anaerobes or mixed bacteria.  Necrosis of superficial fascia results ; underlying muscle are spared .Toxicity is more severe thanWBC counts / fever / hypothermia , hypotension ,tachycardia and lethargy.  Locally the wound is dusky with subcutaneous edema , induration, crepitations , hyperesthesia and bullae formation in skin .  Haemoconcentration ,hypokalemia , hemolysis, hyperbilrubinaemia develop at faster rate.  Hepatic, renal pulmonary insufficincy soon develop and patient is in state of septic shock.
    •  Aggressive treatment started as in cases of major degree burns.  Predisposing factors include --- diabetes , obesity, trauma , alcoholism , immunosuppressive state, hypertension , peripheral vascular disease , IV drug abuse and addiction .  A wide excision and debridement / re debridement is done .  Iv fluid therapy and nutrition with correction of electrolyte imbalance and broad spectrum antibiotics are started ; to be changed as soon the c/s reports are available.
    •  Intestinal Leak It occurs early / late from devitalized / crushed intestine during dissection from pelvic tumors / leaking anastomosis site.  Diagnosed by suspicion / flat plate abdomen in standing posture for gas under diaphragm.  Manage by -- exploratory laparotomy , repair of the damaged gut , peritoneal toileting and drainage , blood transfusion , antibiotics , resuscitation with fluid ,electrolytes minerals , vitamin supplementation . Ketoacidocis is prevented by ensuring adequate total parenteral nutritional therapy; till oral feeding is suspended .
    •  A care full review of history , investigations ,pre / intra , post operative sequence of events .  Through general physical, systemic and operative site examination , Consultation with physician / general surgeon / necessary investigations are the key points in prompt diagnosis of post operative fever.  An early , timely and appropriate diagnosis , immediate treatment helps in minimizing the mortality and morbidity  The presence of non infectious cause of fever does not exclude the possibility of infective reason as both may co –exist.
    •  Fever associate with diarrhoea and central abdominal pain---- Enterocolitis due to c Clostridium difficile.  Calf pain & tenderness--- DVT .  Cough with sputum , breathlessness ---Pulmonary infection .  Urinary frequency , dysurea, haematurtia , urgency supra pubic and loin pain ----UTI / Pyelonephrytis.  Site of pain ---helps in localizing the infection ---wound , IV cannula , catheter site . Intense pain at wound , restlessness with fever may be due to clostridium myonecrosis.  Fever with delirium ---- acute alcohol withdrawal .  Rigors and chills ---atelectasis , malaria / pyelonephritis.  Headache , projectile vomits, stiff neck----Meningitis.  Pain at IM injection site-----injection abscess
    •  Previous H/O pyrexial illness ---Malaria,TB, Sinusitis ,UTI ,pulmonary disease( empyema, plueral effusion bronciectasis ).  Local infection--- vaginal vaginosis, cervicitis , infected fibroid / malignant legion/ decubitous ulcer in case of prolapse , skin infection at the site of skin incision etc  Family or Personal H/O malignant hype pyrexia , thyroid disorder , IV drug abuse , alcohol / tobacco intake , obesity , Pre operative transfusion of blood , fluids . Drugs and drug reaction.  Patients who are more susceptible ---- obese , diabetic , Immuno compromised , taking chemo / radiotherapy , Corticosteroids , debilitating disease, malnutrition , renal / liver insufficency , extremes of age ( old aged ) and BP, cardiac valular disease.
    •  Date of surgery ---exact Post operative day and onset of fever .  Its type and duration ,  Use of Implants—mesh  Type and duration of preoperative antibiotics given .  Pattern of onset of symptoms on which Post operative day . Existing symptoms prior to surgery , investigations / any treatment given and its response .  Any complication during operation / anesthesia.  H/O prolonged ventilation .  Left over packing , swabs or instruments / poor debridement / excision of infected , nacrosed tissue / un recognized / over looked injury to gut.
    •  Monitor vital parameters .  If tachycardia is out of proportion to rise in temperature is an ominous sign as in severe sepsis , associated with hypotension and oliguria.  Tachypnoea --- pulmonary cause .  Pattern , trend and its flctuation should be noted.  Detailed examination of wound– color of skin ( dusky , red, blue/black , indurations , discharge(amount, color , odor , frothing ) , tenderness, necrosis of edges, bulla , crepitations.  if any ,silent dehiscence of wound , presence of cellulitis , fascitis, abscess, haematoma, gas gangrene hyperaesthesia, spreading erythematous streaks.
    •  In early stage of wound infection, there is swelling ,warmth ,redness peri wound edema and increasing tenderness .  Later there are more signs of stephylococcal infection ---maximum erythema and fluctuation ; while with enteric organisms tenderness is more and erythema is minimal.  Other signs of infection like fever , malaise . Leucocytosis ,tachycardia/ chills may develop.  Lymph node draining the infected are may also be involved---to be examined.
    •  All intravenous puncture sites with/ without cannulae along with all drain sites ---to be seen for any evidence of infection as thoroughly as wound site examination.  Nose , throat , ear, chest for infection ---sinusitis , chronic SOM, atelectasis/ consolidation/ collapse of lung / pleural effusion / empyema , Pulmonary embolism .  Abdominal Examination---hepato splenomegaly and tenderness, abdominal distension , tenderness (localized or general ),rebound tenderness , free fluid , characters of intestinal sounds , evidence of peritonitis , intraperitoneal abscess, foreign body , peri nephric abscess, subdiaphragmatic abscess , pelvic abscess(PR / PV if needed needling).
    •  Tenderness over renal , bladder indicate UTI.  Cardiovascular examination----alular disease (SABE)  CNS--- Neck stiffness , neck rigidity , kerning's sign +vet , photophobia , altered level of consciousness ----- exclude meningitis / cerebral infection.
    •  Bacteriological assessment---  Blood culture , urine culture , wound swab culture  sputum/ aspirated pleural fluid / peritoneal fluid . CSF , if LP done  Needle aspirate from indurated area/ sp[reading cellulitis surrounding wound / enlarged lymph node , culture from cannula and catheter on removal.  Stool culture. It should be for identification of Pathogen and their sensitivity to drugs .
    •  Chest X ray --- PA view --- Pneumonia, etelactasis, pleural effusion , pleural thickening , metastasis , Lung collapse. Consolidation , tuberculosis. Chronic bronchitis , cardiomegaly , pulmonary embolism. Pericardial effusion . Mediastinal mass etc.  Flat plate Abdomen --- multiple fluid levels and distended intestinal loops incases of peritonitis., air under diaphragm in cases of intestinal perforation. displacement of gas filled intestinal loops by foreign body, pelvic abscess/ free fluid in peritoneal cavity.
    •  USG Whole abdomen and pelvis ----amoebic liver abscess, spleen and liver enlargement, renal and peri nephric pathology , pelvic abscess, hematoma, forgotten lepard /instrument . Doppler can help in identifying thrombosis.  CAT & MRI can identify abscess , foreign body , hematoma and other lesions .  ECG and Echocardiography ---- myocardial infarction , pulmonary embolism , intra cardiac thrombus , valvular disease .
    •  Infection / pus collection may be located My be --- - endogenous, exogenous ( nurse / doctor , instruments , visitors , aseptica conditions of Hospital ) 1. Intracranial --thorough History , CNs examination , LP , Brain scan---Cat / MRI with dye or without dye. 2. Above Oral Diaphragm –sinusitis, pharyngitis ,Ch. SOM , Parotid abscess ,Tonsillitis ---ENT checkup , throat swab culture . 3. AboveThoraces -abdominal Diaphragm—cardio – respiratory system—History taking , Chest examination , X ray chest , sputum examination, culture , ECG and echocardiogram.
    • 4. Above Pelvic diaphragm --- Symptoms and signs on abdominal ,pelvic , PR , p v examination .Wound examination , flat plate X Ray in standing position , CBC , wound swab culture, USG,TVS , Urine examination and culture , Blood culture , catheter / drain / canola site examination , and culture . 5. In between Pelvic and perineal diaphragm ---- local symptoms of deep seated pain in pelvis and perineum ---local examination --- pelvic and Perineal USG. 6. other sites--- gluteal region , Calf muscles for DVT , Epidural / spinal anesthesia site .
    •  It is directed at the cause .  General Measures---Replacement of fluid loss , maintain input out put , electrolytes, nutrition , avoid development of acidosis, control fever below 1ooF by antipyretics( paracetamol / N-SAIDs and Aspirin ) , cold sponging.  In patient to have an infection , examination to localize the site and source of infection , culture for identification of offending pathogens / their sensitivity to antibiotics --- and appropriate therapy in optimal doses is must.  Surgical intervention may be required in the form of wound debridement , excision of infected wound or diseased organ to eliminate the constant source of infection and drainage of pus collected at any site .
    •  Exploratory Laparotomy when intra peritoneal lesion is suspected .  Septic pelvicThrombophlebitis may develop 2-4 days postoperatively. Clinical signs may be unreliable ; can best be confirmed by Doppler USG / venography . Immediate heparinization and broad spectrum antibiotic therapy should be started.  Patient with septic shock need fluid resuscitation , inotopes , vasoactive drugs are needed to address impending myocardial depression . Mechanical Ventilation with high saturated oxygenation in ICU will be needed.
    •  Careful temperature recording and pulse monitoring will help in early detection of the fever.  Thorough review of each individual- right from the history, pre-op, intra-op, post-op clinical examination and relevant investigations will help to clinch the diagnosis.  Appropriate conservative/ operative management should be started as early as possible and if needed, second opinion from fellow colleagues- physician, surgeon and anesthetist, microbiologist should be sought.