POSTOPERATIVE PYREXIA

Z AAT I L I F F AH AS M A WI

OUTLINE
Introduction Differential diagnosis for postoperative pyrexia Initial assessment and work up Management of postoperative pyrexia Conclusion

INTRODUCTION
Definition: T > 38C (100F) on 2 consecutive postoperative days OR T > 39C (102.2F) on any 1 postoperative day Incidence: 14-90% (<10% infectious) Most are self-limiting, but do not miss serious aetiologies. Wait & see, further work up or immediate action?

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
IL-1, IL-6, TNF- , INF- (levels correlate with magnitude of fever) ant hypothalamus endothelium production of PGE2 and cAMP mediate febrile response through conservation + production of heat

CAUSES OF POSTOP PYREXIA

5 Ws Day 1 2 Day 3 5 Day 4 6 Day 5 7 Day 7 +

Wind aspiration, atelectasis, pneumonia Water UTI Walking DVT, PE Wound SSI Wonder drugs

CAUSES OF POSTOP PYREXIA

Common
Superficial thrombophlebitis Abdominal abscess Foreign body infection Catheter-related IV infection Sepsis Pneumonia Haematoma DVT Pulmonary embolism

Uncommon
Acute gout Necrotising fasciitis Acalculous cholecystitis Seroma Alcohol withdrawal Malignant hyperthermia Fat embolism Myocardial infarction Pancreatitis Underlying malignancy

CAUSES OF POSTOP PYREXIA

5Ws as rough guide What can kill this patient if I miss the diagnosis? Early fever not infectious except nec fasciitis Fever day 5: ~ 90% infectious

FIRST 48 HOURS
Pyrexial response to tissue injury
The more traumatic the surgery, the higher the risk of postop fever Resolves within 2-3/7

Transfusion reaction @ allergic reaction

Rash, pain, shock

Alcohol withdrawal
+ altered mental state

Pre-existing infection
E.g. CAP

FIRST 48 HOURS
Necrotising fasciitis
Group A haemolytic strep Staph aureus Up to 70% mortality, higher if premorbid factors and late presentation

Malignant hyperthermia
Autosomal dominant Reaction to GA drugs (succinylcholine, volatile agents Hypercatabolic state: T, HR, RR, CO2, O2 consumption, acidosis, rhabdomyolysis

DAY 1 2
Atelectasis
No consensus GA increased secretions, reduced cough, being on a ventilator Supine position Incisional pain reduced breathing + cough effort

Aspiration
GA Immobility

DAY 3 5
UTI
Higher incidence in females and prolonged catheterisation (Foley)

IVL infection
Cellulitis @ thrombophlebitis of peripheral lines Bloodstream infection if central line

DAY 3 5
Other infections
Bronchopneumonia, esp in pts with underlying CLD, chest surgery, mech ventilation Intraabdominal infection, esp after abdominal @ pelvic surgery subphrenic + pelvic abscess Sinusitis if prolonged NG tube Foreign body infection (prostheses, grafts, stents), usually Staph aureus

DAY 5 7
VTE
DVT higher in higher in pelvic, orthopaedic and general surgery than head+neck surgery in older, obese, immobile, underlying malignancy

Anastomotic leakage or breakdown

new abdominal pain, distension, peritonism, hypotension, tachycardia, fistula small leaks common, cause small localised abscesses + delayed recovery of bowel function resolves with IV fluids and delayed oral intake major breakdown generalised peritonitis and progressive sepsis

DAY 7 +
Drugs
Antibiotics: penicillins, cephalosporins, sulfonamides, vancomycin, rifampicin Diuretics: thiazide, furosemide, spironolactone Anticonvulsants: phenytoin Others: salicylate, NSAID, allopurinol, PTU

SSI
Type + length of surgery, prophylactic antibiotics, condition of patient, co-existing diseases risk in diabetes, obesity, length of preoperative stay

DAY 7 +
Wound dehiscence
Esp midline laparotomy Mortality up to 30% d/t infection, poor healing (malnourished, elderly, immuno-compromised), poor suturing technique Serous discharge protrusion of bowel loops

HOW TO APPROACH THE PATIENT WITH POSTOPERATIVE FEVER

History
Current symptoms: pain, SOB/cough, PU+BO Pre-operative course: underlying conditions (malignancy, immunosuppression), mobility Details of surgical procedure: emergency @ elective, duration, site, nature of foreign body (prostheses, implants, stents etc), prophylactic antibiotics, blood products + drugs administered, complications Previous use of tobacco, alcohol, IVD History of pyrexia related to surgery @ family hx of malignant hyperthermia Prior transfusions, drug hypersensitivities/allergies Nursing: sputum, diarrhoea, skin rash/breakdown

 Examination (top to toe)

Vital signs including T: rectal or oral, but consistent site
High + swinging in pus collection (abscess, empyema) Low + grumbling in thrombophlebitis, DVT, atelectasis

Mental state NG tube Lungs CVS: tachycardia, new murmur IV lines Surgical site: inflammation, tenderness, wound + sutures, drains Abdomen: distension, tenderness, BS Urinary catheter Skin: rashes, haematoma Joints: inflammation Lower limbs: inflammation, tenderness

 Investigations
Should be used sparingly and only as directed by the history and physical examination Laboratory
UFEME Urine C+S, sputum C+S, wound swab C+S FBC, LFT, D-dimer, ABG Blood culture if high clinical suspicion @ high risk patients: septiclooking, immunocompromised, central line, obvious wound infection Septic work up if cause unclear

Radiological
CXR (atelectasis, pneumonia, leakage) Abdominal US, Doppler US CT scan, e.g. abdomen if recent intra-abdominal surgery and suspect collection

MANAGEMENT (GENERAL)
Prophylaxis: optimise pt pre-op (DM, HPT, lung function), prophylactic antibiotics, aseptic/sterile techniques of procedures (even cannulation!), DVT prophylaxis in high risk pts ABC and resuscitation Antipyretic to reduce fever and decrease discomfort Remove/stop unnecessary/harmful treatment and lines/catheters Antibiotics: withhold if patient well until known cause, empirical if suspect infection + patient unwell taper to C+S results

SPECIFIC MANAGEMENT
Atelectasis: pain control, incentive spirometry + chest physio, mobilisation

Necrotising fasciitis: IV antibiotics (penicillin, metronidazole, ceftriaxone), surgical debridement Malignant hyperthermia
IV dantrolene (muscle relaxant) discontinuation of triggering agents, supportive therapy to correct hyperthermia, acidosis, organ dysfunction

UTI: remove catheter, antibiotics VTE: heparin, warfarin

SPECIFIC MANAGEMENT
SSI: open drainage, antibiotics Anastomotic leakage: IV antibiotics, surgery, ICU, nutrition if enteric fistula Intraabdominal collection: drainage (radiologyguided, surgically if inaccessible), IV antibiotics, analgesia

CONCLUSION
Postoperative fever should alert caregiver to possibility of infection complicating recovery, but presence of fever not reliable indicator infection and absence of fever does not guarantee that the patient is infection-free. Non-infective causes have a better outlook than infective causes. The outcome for the infected patient is dependent on the rapid identification of the cause, appropriate resuscitation, antibiotic treatment and appropriate surgery to eliminate the source.

THANK YOU!
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