Post Operative Fever - Surgeon's Envy

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Fever in post-operative period is tension giving to a caring surgeon. Apart from a major surgery under general anaesthesia where transient fever may occur on first day, fever is not welcome.
Therefore, try to find out the cause and treat accordingly.

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Post Operative Fever - Surgeon's Envy

  1. 1. POST OPERATIVE FEVER – SURGEON’S ENVY
  2. 2. Thermoregulation  Balance between heat production and heat loss  Heat production-oxidative process  Catacholamines  Thyroxin  Increase in substrate load in metabolic pathway  I/3 of Heat producing activity takes place in muscle mass-increase in muscular activity like exercise or shivering has considerable effect on heat production.
  3. 3. Heatloss  Conduction & Convection  Vasodilatation(transfer of heat from core to surface)  Evaporation – sweating,most important mechanism of heat expenditure
  4. 4. NORMAL BODY TEMP  Normal body temp. 36.2-37.5C(97-99° F)  Diurnal variation 0.5 to 1.5 °C (0.9-2.7°F.)  Low in morning hours, max in evening  Hypothalamus regulates this-input from temperatura sensitive nerve endings in viscera, skin, temp. sensitive receptors in Ant .Hypothalamus  Temp. regulatory neurons in post hypo alter sweating, by vasoconstriction, vasodilatation and hormonal regulation  Local spinal cord reflexes also regulate vasodilatation, and vasoconstriction.
  5. 5. PATHOGENESIS OF FEVER  FEVER means Heat prod or Decrease heat expenditure  Insufficient sweating or by vasoconstriction  Increase Heat production -  Elevation of Catecholamines or thyroxin  Inappropriate shivering or abnormal muscle activity.  PYROGENS - A febrile reaction is initiated by pyrogens. May be Exogenous or Endogenous
  6. 6. Classification of Fever  INTERMITTENT (Spiking)  Intermittent elevation of temp with regular return to normal (infection within closed space-abscess)  REMITTENT/FLUCTUATING Continuous type of fever drop in fever without returning to normal-brucellosis, blood stream infections, infected arterial grafts, phlebitis.  UNREMITTING/CONTINUOUS Continuous high fever-CNS injury, pneumonias, typhoid Note: Hydration, Muscle activity, sleep and medication also alter febrile response.
  7. 7. Altered Febrile Response  AGE;  INFANTS HAVE A HIGH TEMP ranging as high as 40.6  OLD AGED Patients - DIMNISHED RESPONSE  MEDICATIONS- NSAID, Steroids-absence of fever  TRAUMA-  Fever in trauma is bad sign, trauma to hypothalamus disturbs thermoregulatory mechanism .  IMMUNOSUPRESSION- Altered production of endogenous leukocyte, pyrogens, lack a febrile response
  8. 8. FEVER IN POST OPERATIVE PATIENT WIND,WATER,WOUND
  9. 9. FEVER IN POST OPERATIVE PATIENT  WIND , WATER, WOUND  COMMON CAUSES  ATELACTASIS  VENOUS THROMBOSIS  URINARY TRACT INFECTION  SURGICAL WOUND INFECTION
  10. 10. DAY 1 -2 (24 – 48 HRS.) FIRST DAY FEVER ATELACTASIS
  11. 11. ATELACTASIS OR PNEUMONITIS  Anesthesia agents cause increase production of secretions, as water evaporates, they become viscous.with diminished cough reflex & decrease ciliary activity - formation of mucus plug- obstruct small airways. When the gases distal to plug get absorbed the airways collapse.  Febrile response is due to Low grade infection distal to obstructing plug and absorption of bacterial pyrogens  Temp elevation within 12 hrs of onset of plug formation.max temp is characteristically 38.9 degree centigrade
  12. 12. PNEUMONITIS  High risk group - Cigarette smoking, chronic bronchitis, COPD  3% of all ORS, 15% abdomen, 25% upper abdomen  Continued atelactasis predispose to full blown Pneumonitis  Prevention:  Assessment of patient, Avoid General Anaesthesia, Stop smoking, spirometery, Assess pulmonary mechanics, Thick mucus secretions need inhalations to FOB, chest physiotherapy, early mobilization.
  13. 13. THIRD DAY SURGICAL FEVER 48-72HRS TEMP ELEVATION TO 40.6 TO 41.1 Phlebitis
  14. 14. PHLEBITIS  IV catheter sepsis  DVT and Pulmonary embolism  Suppurative thrombophlebitis
  15. 15. Temp elevation to 40.6-41. 1°C  Tachycardia, Hypotension, Oliguria, Prostration, Leukocytosis, Hard chills-52%develop septic shock, mortality rate 40% in 40yrs above age and 80% in above 80yrs age.  Tenderness and erythema around catheter.  Precipitating causes:  Hyperosmolar infusate, K conc sols, antibiotics, size of vein in which catheter. This can be decreased by adding one unit of heparin. IV septic technique  Cathater sepsis reduced from 23% to 4% keeping Intravenous catheter in place for max 12 hrs.
  16. 16. IV catheter sepsis  Lack of aseptic technique  Use of hypertonic solutions  Multiple infusions through same line  Change of site after 72 hrs.  Early signs-Red streaks
  17. 17. THIRD AND FOURTH DAY FEVER DVT & PULMONARY EMBOLISM
  18. 18. DVT & PUL. EMBOLISM  3 -4 days Temp elevation, calf Tenderness (Homan’s sign)  Doppler ultrasound, has replaces contrast venograms  Treatment is PREVENTION  Identify High risk group from pre-op stage.  Start prophylactic heparin sub cut peri-operative  Mechanical means
  19. 19. PULMONARY EMBOLISM  SEQUELAE OF DVT  FEVER DOES NOT APPEAR UNTIL PUL THROMBO EMBOLISATION-PAIN CHEST, DYSPNOEA,  TREATMENT IS PREVENTION  THERAPEUTIC DOSE OF HEPARIN  NEED HDU
  20. 20. SUPPURATIVE THROMBOPHLEBITIS  PRESENCE OF SUPPURATIVE INFECTION IN VEIN IS OFTEN LETHAL-NEED LIGATION OF VEIN  HIGH FEVER , REMITTENT TYPE  COMMON SITES ARE; Basilic,Cephalic, Neck veins  OCCASIONALLY SEEN IN PELVIC VEINS after SEPTIC ABORTION, AND PID.
  21. 21. URINARY TRACT INFECTIONS  Most common nosocomial infection (40%)  75% patients have some form of urine tract manipulation  Bacteria found in urine in 1-5% of patients undergoing short term catheterization, 90% pts in whom Foley is left for 48hrs or more  Post op UTI; temp 39.4-40°C, rigors/chills  Management –prevention, PUT Catheter only when must, Aseptic technique , closed drainage system. Discard drainage system if accidentally disconnected and change when obstruction or contamination occurs.
  22. 22. DAY 5-8 FEVER Surgical wound infection
  23. 23. SURGICAL INFECTION  Wound infection‘ present as abscess-cellulites  Signs of erythema, foul discharge, indurations, soakage  Treatment is adequate drainage &/antibiotic coverage  Factors responsible-patient related , disease related, procedure related, environment related.  Lack of preventive measures.
  24. 24. BENIGN POST OPERATIVE FEVER  During Operation Thermo regulatory mechanism Hypothalamus becomes inhibited by Anesthetic agents –fall in body temp, thermo neutrality with atmosphere  Once anesthesia effect is gone- recovery of this mechanism but intracranial core temp still decreased-thermosenstive receptors in hypothalamus sense decreased temp and attempt to raise body temp to hypothalic set point, often there is over compensation with a mild febrile episode in post op period  This is diagnosed by exclusion
  25. 25. Other non surgical Causes…..  MALARIA, BRUCELLA, TYPHOID.  MALIGNANT DISEASES  POST CARDIOTOMY FEVER SYNDROME  BLOOD TRANSFUSION  PHAYNGITIS - OTITIS  ADDISONIAN CRISIS
  26. 26. OTHER CAUSES  Hyper metabolism -increased BMR in response to surgery –burn pt, returns to normal with wound healing  Drug induced Fever  DEHYDRATION-decreased sensitivity to sweating mechanism  Malignant Hyperthermia  THYROID STORM  FEVER OF CNS ORIGIN
  27. 27. DRUG INDUCED FEVER  Drugs that cause fever due to effects of pharmacological activity; Antibiotics, Cytotoxic agents  Drugs causing fever due altered thermoregulation  Atropine, Catacholamines, (Decrease sweating)  Increased BMR- thyroxine derivatives  Drugs causing fever due to contaminants;  IV solutions  Drugs that cause fever indirectly; anticoagulants  Drugs causing fever due to hypersensitivity-sulphas, penicillins,
  28. 28. MANAGEMENT OF POST OP FEVER  Measures/procedures to determine cause  History;onset,type, medication-blood transfusion  Exam;chest, IV sites, lower limbs DVT, calf tenderness, ENT exam, assess Hydration,  Lab work. CBC, urine routine/cs, Chest X-Ray,  C/s-Throat, nasopharynx, wound, blood culture ( x2 )if temp >38.9  Culture; Drain or tube, or cath tips, iv caths  Typhoid, Brucella-tests.  Treat; underlying cause. Treat fever, maintain hydration, nutrition
  29. 29. SUMMARY  Fever is common and readily detectable manifestation of disease .In the post op pt the most common potentially serious causes are atelactasis or other pulmonary problems, phlebitis in deep veins or at iv sites, UTI, and surgical wound infection.  Other benign and potentially serious causes occur less commonly but must be suspected when more common causes are not found. treatment directed towards cause. Fever controlled by salicylates and by mechanical means if control is warranted,

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