3. Introduction
• Fever is common in the first few days after major surgery and cause a diagnostic
challenge for the care team.
• Postoperative fever is defined as Temp. > 38°C on two consecutive postoperative
day(POD) or > 39°C on any POD.
• "Physiologic fever ": < POD 3, inflammatory stimulus of tissue damage and
exposure to foreign materials.
• Starting on POD 4, infections related to the surgical procedure are more
common.
7. Immediate (within hours of surgery)
• Surgically induced inflammation — inflammatory pyrogenic cytokine occur as a
response to surgical stress. Over half of these patients had a maximum temperature measured
exceeded 38°C.
• Immune-mediated reactions — reactions to antimicrobials and transfused blood products in OR.
These reactions often resolve after the transfusion or when the medication is discontinued but
should be noted as possible transfusion reaction or medication allergy(hypotension/rash).
• Malignant hyperthermia —is an inherited disorder, typically presents within 30 minutes
following the administration of a triggering agent (eg, inhaled anesthetics, succinylcholine)
-Dantrolene, loading dose of 2.5 mg/kg IV (For a 70 kg patient, 175 mg will be required.)
• Preexisting infection — Peritonitis, sepsis, abscess…
8. Immediate - Evaluation
• 1.Initial assessment includes general appearance, GCS,
and vital signs, oxygen, rash.
• 2.System based assessment (pulmonary, cardiac, abdomen, surgical site, catheter)
• 3.Besides tests, ECG, ABG(Lac),Glu test
• 4. Blood tests: WBC, CRP, hemoglobin, renal function, liver function tests, coagulation
parameters, electrolyte.
• 5.Check patient notes (type of surgery, intraoperative timing & complications,
anesthesia records, patient comorbidities, last ward rounds)
• 6. Check patient I/O(Oral, IV, Urine, Stool, drainage, exudate)
9. Early (first three days after surgery)
• Community-acquired infection that predates surgery, such as a viral URTI.
Nosocomial infections are not common during this period.
• Myocardial infarction: risk will decreases after the first 72 hours
• Urinary tract infection: catheter-related infection
• Early surgical site infection: group A streptococcus and clostridium perfringens, can
cause fulminant SSI
• (Aspiration)pneumonia: patient has vomited when the gag reflex is suppressed by
anesthesia or analgesia needed for endotracheal intubation.
• Other noninfectious causes: pancreatitis, venous thromboembolism, alcohol
withdrawal, gout flare or thyrotoxicosis.
10. Early - Evaluation
• 1.Initial assessment includes general appearance, GCS, vital signs, SpO2.
• 2.System based assessment (pulmonary, cardiac, abdomen, surgical site, catheter, I/O)
• 3.Sites of infection that are visible (i.e., Skin for bedsores, cellulitis, vascular access sites)
• 4.Besides tests, ECG, ABG(Lac),Glu test
• 5. Imaging: chest x-ray
• 6. Blood tests: WBC, CRP, hemoglobin, renal function, liver function tests, coagulation
parameters, electrolyte.
• 7. Microbiology: cultures (blood, urine, wound, and sputum)
• 8.Check patient notes (type of surgery, intraoperative timing & complications,
anesthesia records, patient comorbidities, last ward rounds)
11.
12.
13.
14. Late — After POD 3
• Surgical site infections can be classified as superficial, deep or organ/space
• Surgery-specific complications: anastomotic leaks can lead to deep/organ space
infections, abscesses, or fistulae.
• Nosocomial infections are more common in these patients because of their treatment
with invasive medical devices.
• Noninfectious causes of fever in the late postoperative period include febrile drug
reactions, venous thromboembolism.
15. Late - Evaluation
• 1.Initial assessment includes general appearance, GCS, and vital signs.
• 2.Check patient I/O(Oral, IV, Urine, Stool, drainage, exudate)
• 3.System based assessment (pulmonary, cardiac, abdomen, surgical site, catheter)
• 4. Drainage work-up: cell count, biochemical, Amylase, bile, LDH, protein, culture.
• 5.Sites of infection that are visible (i.e., Skin for bedsores, cellulitis, vascular access sites)
• 6. Microbiology: cultures (blood, urine, wound, and sputum)
• 7. Imaging: chest x-ray, abdominal imaging (ultrasound, CT scan to rule out collections)
16. • 12.Venous doppler of the legs to rule out deep vein thrombosis
• 5.Check patient IPS (antibiotics, venous thromboembolic prophylaxis)
• 3.Check patient notes (type of surgery, intraoperative timing & complications,
anesthesia records, patient comorbidities, drain position)
Late - Evaluation
17.
18. Delayed - more than 30 days after the procedure
• Implanted devices such as hernia mesh or orthopedic prostheses and development of
delayed fistulae.
20. Treatment
General measures
Resuscitation, as needed.
Control pain.
Antipyretics – Acetaminophen is often appropriate to reduce fever but should be avoided
in patients with alcohol use disorder, starvation, or hepatic impairment.
Empiric antimicrobial therapy is reasonable in patients who likely have infection as a
cause of postoperative fever. should administered after cultures obtain.
Specific treatment
Source control of infection (eg, abscess drainage, removal of
catheters).
21. Recommendations for empiric antibiotic therapy
Early onset, no risk factors for MDR
organisms*
o Ceftriaxone
o Levofloxacin, moxifloxacin,
or ciprofloxacin
o Ampicillin/sulbactam
o Ertapenem
Late onset, risk factors for MDR
organisms
o Antipseudomonal cephalosporin
(cefepime, ceftazidime) OR
o Antipseudomonal carbapenem
(imipenem or meropenem) OR
o b-lactam/b-lactamase inhibitor (piperacillin-
tazobactam)
plus
o Antipseudomonal fluoroquinolone OR
o Aminoglycoside
plus
o Linezolid or vancomycin
*Risk factors for MDR pathogens: > 5 days after hospitalization, admission from a healthcare-related facility, antibiotics in the
previous 90 days, high frequency of resistance in the community or hospital unit, immunosuppression
22. • In a systematic review of patients with drug fever, only 18% had a reported rash,
only 22% had eosinophilia and relative bradycardia was reported in only 11 %
Drug fever
24. Prevention
• Increases the risk of postoperative infection is nasal staphylococcus aureus carriage.
• Mupirocin nasal ointment has been shown to reduce the incidence of surgical site
infections with staphylococcus aureus, especially in the non-general surgery population
(cardiothoracic, orthopedic, and neurosurgery)
25. • Steps to ensure prompt weaning from mechanical ventilation are important, such as
“lightening” sedation on a daily basis.
• Fowler’s position and regular tracheal suctioning are recommended to prevent aspiration
of orotracheal secretions.
26. SSI prevention
• An effective program can reduce the rate of SSIs by 40%. In addition to a clean operating room
environment, the most important factors in the prevention of SSI are timely administration of
effective preoperative antibiotics and careful attention to operative technique.
27. Stringent glycemic control
• Important for reducing the risk of surgical site infection and promoting wound
healing. Hyperglycemia has been associated with a higher incidence of nosocomial
infections overall;
• In one large randomized trial insulin administration to keep blood glucose below
6.1mmol/L was associated with a 40% decrease in mortality.
31. Reference
• 1. O'grady NP, barie PS, bartlett JG, bleck T, garvey G, jacobi J, et al. Practice guidelines for evaluating new fever in critically ill adult
patients.Task force of the society of critical care medicine and the infectious diseases society of america. Clin infect dis. 1998
may;26(5):1042-59. [Pubmed]
• 2. Garibaldi RA, brodine S, matsumiya S, coleman M. Evidence for the non-infectious etiology of early postoperative fever. Infect control.
1985 jul;6(7):273-7. [Pubmed]
• 3. Held BI, michels A, blanco J, ascher-walsh C. The effect of ketorolac on postoperative febrile episodes in patients after abdominal
myomectomy. Am J obstet gynecol. 2002 dec;187(6):1450,5; discussion 1455. [Pubmed]
• 4. American thoracic society, infectious diseases society of america. Guidelines for the management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated pneumonia. Am J respir crit care med. 2005 feb 15;171(4):388-416. [Pubmed]
• 5. Calandra T, cohen J, international sepsis forum definition of infection in the ICU consensus conference. The international sepsis
forum consensus conference on definitions of infection in the intensive care unit. Crit care med. 2005 jul;33(7):1538-48. [Pubmed]
• 6. Warren JW. Catheter-associated urinary tract infections. Infect dis clin north am. 1997 sep;11(3):609-22. [Pubmed]
• 7. Sedor J, mulholland SG. Hospital-acquired urinary tract infections associated with the indwelling catheter. Urol clin north am. 1999
nov;26(4):821-8. [Pubmed]
• 8. Kauffman CA. Candiduria. Clin infect dis. 2005 sep 15;41 suppl 6:S371-6. [Pubmed]
• 9. Mangram AJ, horan TC, pearson ML, silver LC, jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for
disease control and prevention (CDC) hospital infection control practices advisory committee. Am J infect control. 1999 apr;27(2):97,132;
quiz 133-4; discussion 96. [Pubmed]
• 10. Barie PS, eachempati SR. Surgical site infections. Surg clin north am. 2005 dec;85(6):1115,35, viii-ix.
Editor's Notes
Assist & modifty
Identify the common etiologies of postoperative fever.
Summarize the evaluation of a patient with post operative fever.
Outline the treatment and management options available for post operative fever.
Describe interprofessional team strategies for improving care and outcomes in patients with post operative fever.
Daily incidence of index postoperative complications.
Share of daily complications over 30 postoperative days among surgical patients.
inflammatory pyrogenic cytokine mediators (such as interleukin [IL]-1, IL-6, tumor necrosis factor, and interferon gamma)
The vasodilation that often accompanies these reactions makes hypotension a common presenting sign; rash may accompany fever in some patients with medication reactions.
bacterial peritonitis due to a perforated viscus of the abdomen
If the patient is hypotensive, venous blood gas is needed to measure serum lactate. It will guide fluid resuscitation; if the patient is tachycardic, bedside ECG might be important to confirm their rhythm, might rule out myocardial infarction; oxygen saturation, blood glucose levels because high blood glucose levels point towards septic response.
If the patient is hypotensive, venous blood gas is needed to measure serum lactate. It will guide fluid resuscitation; if the patient is tachycardic, bedside ECG might be important to confirm their rhythm, might rule out myocardial infarction; oxygen saturation, blood glucose levels because high blood glucose levels point towards septic response.
Other Ws have been proposed, including "Waves," "Wonky glands," "Withdrawal," and "What did we do?". These are reminders to consider cardiac and endocrine causes(thyroid storm); alcohol and other substance withdrawal; and other treatments such as medications, blood product transfusions, and intravascular, urethral, nasal, and abdominal catheters as potential causes for a patient's postoperative fever.
Hypotension,sepsis
Fowler’s position Semirecumbent positioning at a 30-45 angle
A number of other perioperative infection control interventions have been used to reduce the risk of SSIs, including hand hygiene, use of gloves and other barrier devices by operating room personnel, patient decolonization, skin antisepsis, and method hair removal
The diagnosis and management of postprocedure fever can be challenging.
it is imperative that the evaluation take into consideration both noninfectious and infectious causes.
the timing of the onset of fever in relation to the procedure (immediate, early, late or delayed) can differentiate likely diagnoses. A thorough history and physical examination are mandatory and will guide further diagnostic workup. Blood cultures, urine cultures, as well as routine laboratory studies can also aid in diagnosis. That’s all of this topic.
http://www.antimicrobe.org/e23.asp
Signs of Organ Dysfunction:
Systolic BP less than 90 mm Hg or mean arterial pressure less than 65 mm Hg.
Drop in BP greater than 40 mm Hg (especially in hypertensive patients)
Lactate greater than 2 mmol/L
Urine output less than 0.5 mg/kg/hr for 2 consecutive hours
Drop in Glasgow coma scale (GCS) or abbreviated mental test scores
