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Postoperative fever

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Postoperative fever

  1. 1. Post-operative fever
  2. 2. Febrile Surgical Patient • Common • Long list of differential diagnosis • Understandable to equate fever with infection • Workup and therapy should be individualized
  3. 3. What constitutes a fever? • • • • Arbitrary Temperature that raises concern > 38oC Increased metabolic rate 7% -15% / oC – little morbidity aside of discomfort and increased insensible fluid loss • But risk of neurological injury if > 41 oC
  4. 4. Noninfectious Causes of Fever • Nosocomial infection unlikely in the first 48 hours after operation • The most common cause of postoperative fever is ATELECTASIS
  5. 5. Causes of post-op fever • Non-infectious • Infectious – Device-related – Not related to devices
  6. 6. Other Noninfectious Causes • • • • • • Aspiration pneumonitis Tissue ischaemia Haematoma Transfusion reaction Gout/Pseudogout Withdrawal of ethanol, sedatives, or opioids • Endocrine emergency – thyrotoxicosis / adrenal insufficiency
  7. 7. Drug fever • • • • • Only 2 - 3% of all post-op fever Usually due to hypersensitivity Antibiotics most common Diagnosed by exclusion Fever often subsides after removal of drugs • Malignant hyperthermia • Neuroleptic malignant syndrome
  8. 8. Haematological Fever • Transfusion reaction – passenger leukocytes leads to alloimmunization to leukocyte-specific antigens in the recipient • Deep venous thrombosis • Haematoma
  9. 9. Infectious Causes of Fever • If operation is performed for control of an infection, the fever is expected to settle within 72 hrs • New or persistent fever more than 3 days after surgery should raise a strong suspicion of persistent sepsis or a new complication
  10. 10. Device-related infection • Nosocomial infection often arise in association with indwelling devices: – IV drips – ET-tube, tracheostomy tube, NG tube – Urinary catheters – Drains
  11. 11. Nosocomial Chest infection • After 3rd day • Risk factors: – prolonged mechanical ventilation – cardiothoracic, neurosurgical, trauma operation – major H&N or GI surgery • purulent sputum, fever, high WCC, and abnormal CXR
  12. 12. Urinary tract infection • Seldom destabilizing • Upper tract rare • Most important risk factor – duration of catheterization • Indication of cath should be reviewed daily • Remove at the earliest opportunity
  13. 13. Infection of vascular Access • Central or peripheral lines • Percutaneously placed catheter should be removed • Surgically placed catheter (e.g. Hickman line) may be salvaged by antibiotics (successful if Gram positive infection, not likely if infected by pseudomonas or fungus)
  14. 14. Nosocomial Infection not related to Devices • Wound infection • Necrotizing fasciitis • Pseudomembranous colitis • Acalculus cholecystitis
  15. 15. Approach to Post-op Fever • An individual approach is essential • Unlikely diagnoses should not be pursued until more common causes have been excluded • Important to differentiate whether the fever is due to infection or just an inflammatory response only
  16. 16. Approach to Post-op fever according to time of onset
  17. 17. Day 1 • Most common: atelectasis • Persistent sepsis if OT was done for control of infection • Rare causes: • • • • thyroid crisis transfusion reaction drug fever malignant hyperthermia / NMS
  18. 18. Day 2 - Day 3 • Infection related to indwelling device – Drip site infection – Chest infection / Sinusitis – Bacterial cystitis • Haematoma • Tissue necrosis (e.g. flap) • Gout / pseudogout
  19. 19. Day 4 - Day 5 • Wound infection • Anastomotic leak • Intra-abdominal abscess / collection • Rare causes – Antibiotics induced colitis – Acute acalculous cholecystitis
  20. 20. Day 6 - Day 7 • All of the above and, • Deep venous thrombosis • Pulmonary embolism
  21. 21. Approach to Post-op Fever • Careful review of history – Premorbid condition – Indication of surgery – Nature of operation • Physical examination – Chart of vital signs – Possible source of infection • Consider culture of blood, sputum and urine • CXR, +/- USG abdomen +/- CT scan • Empiric antibiotics if necessary
  22. 22. Miss Emily Cheung (Ext 2679) emilycheung@surgery.cuhk.edu.hk

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