Post operative fever

POST
OPERATIVE
FEVER
Dr. Mayur Patel

FEVER
• Fever is an elevation of body temperature that exceeds the normal daily
variation and occur in conjunction with an increase in hypothalamic set
point.
• At 6 am – more then 98.9oF
• At 4 pm – more then 99.9oF

TYPE OF FEVER
• Continuous –
• fever occur all over 24 hour with diff b/w max and min is less then 1oC
• Eg. 1st week of typhoid fever

TYPE OF FEVER
• Intermittent – fever occur daily but touches to normal limit once during 24
hour.
Accourding to pattern they can be
 Quatidian – fever every 24 hour (P. Falciparum, TB, UTI)
 Tertian – fever every 48 hour (P. Vivax)
 Quartan – fever every 72 hour (P. Malaria)

TYPE OF FEVER
• Remittent –
• fever occur all over 24 hour with diff b/w max and min is more then 1oC and
never touches to normal limit.
• Eg. 2nd week of typhoid fever

TYPE OF FEVER
• Relapsing –
• period of fever followed by period of normal tempurature.
 Pel-ebstein fever – in hodgkins
 Cyclic netropenia

POST OPERATIVE FEVER
• Most of the time post operative fever occur within 72 hours and non-
infectious.
• Fever that occur after 4 days of major operation is mainly caused by
underlying infection

PHYSIOLOGY OF POSTOPERATIVE
FEVER
OPERATION ASSOCIATED WITH TISSUE DAMAGE AND INFLAMMATION
ACTIVATION OF MACROPHASE, ENDOTHELIAL CELL, RETICULOENDOTHELIAL SYSTEM
RELEASE OF IL-1, IL-6, TNF, INTERFERON-GAMMA
ACT ON PRE-OPTIC NUCLEUS OF HYPOTHELEMUS
PG-E
INCREASE HYPOTHELEMIC SET POINT

7 “W” OF POSTOPERATIVE FEVER
• WIND
• WATER
• WOUND
• WALK
• WONDER DRUG
• WITHDRAWAL
• WONKY GLAND

WIND – ATELECTASIS
• ATELECTASIS - is the collapse or closure of a lung resulting in reduced or
absent gas exchange.
• WITHIN 48 HOUR OF POSTOPERATIVE PERIOD
• CAUSE :
• Postoperative patients spend the majority of their day sitting or
lying in bed, which leads to incomplete expansion and resulting
atelectasis.
• Patients may have poor inspiratory effort due to sedation or pain
and may be unable to clear the pulmonary secretions that are
common following intubation and general anesthesia.

• Signs and symptoms of atelectasis include –
 tachypnea,
 dyspnea,
 cough,
 decreased breath sounds,
 crackles,
 hypoxemia, and
 dependent infiltrates on chest radiography.

• Identification and treatment of atelectasis are important in the early
management of postoperative patients because rates of healthcare-
associated pneumonia increase after the first 48 hours.
• Treatment for atelectasis
 increased pulmonary hygiene: deep inspiration assisted by
incentive spirometry,
 early mobilization,
 chest physiotherapy, and
 bronchodilators.

WATER - UTI
• WITHIN 48 TO 72 HOUR
• Risk factors
 length of catheterization,
 unsterile placement or care of a urinary catheter,
 female sex,
 older age,
 history of diabetes, and
 history of previous UTIs.

WATER - UTI
• Many patients with UTIs are asymptomatic and do not require treatment.
In these cases, treatment does not improve outcomes and can increase
rates of antimicrobial resistance.
• Symptoms of UTI include
 fever,
 suprapubic or flank pain,
 costovertebral angle tenderness, and
 urinary urgency

WATER - UTI
• Obtain a urinalysis and urine culture with sensitivity for patients with
symptoms suggestive of a UTI. Positive results requiring treatment
include……
 pyuria,
 positive leukocyte esterase,
 positive urine nitrites, and
 bacterial culture showing more than 10 cfu/mL of the offending
organism.

WATER - UTI
• The most common causative organisms implicated in catheter-associated
UTI are
 E. coli (27%),
 Enterococcus spp (15%),
 Candida spp (13%),
 P. aeruginosa (11%), and
 Klebsiella spp (11%);

WATER - UTI
• empiric treatment should be aimed at these pathogens with tailoring to
specific organisms once culture data are available.
• Empiric treatment while awaiting culture data is contingent upon the
degree of patient illness, comorbid conditions, previous culture results,
and local resistance pattern.

WOUND - SSI
• SURGICAL SITE INFECTION – Surgical site infections (SSIs) are defined by
the CDC as infections that occur at or near the surgical incision within 30
days of surgery or within 90 days if prosthetic materials have been
implanted.
• POST OPERATIVE DAY 5 TO 10
• SSI is rare in first 3day except
• Group A streptococcal
• Clostridial infection

WOUND - SSI
• RISK FACTOR –
 older age,
 poor nutrition,
 Obesity,
 history of diabetes,
 Smoking
 other concomitant infections,
 impaired immune status,
 previous history of colonization

WOUND - SSI
classified as
• superficial (skin and subcutaneous tissue only),
• deep (involving fascia and muscle), and
• organ/space infection

WOUND - SSI
• Collect specimens of the purulent drainage for culture because they
typically are needed for microorganism identification and antimicrobial
sensitivities to tailor treatment.
• Avoid routine culture swabs of incisions, which can be contaminated with
skin flora.
• Patients with signs of severe illness (such as high fever, leukocytosis, or
hemodynamic instability) out of proportion to skin findings may need
radiographic studies, such as ultrasound or CT, to identify deep or
organ/space infections.

WOUND - SSI
• The most common pathogens that cause SSI are skin flora, such as species
of
 Streptococcus,
 Staphylococcus, and
 Enterococcus

WALKING – DVT AND PE
• Postoperative patients account for 20% of all hospital-acquired deep vein
thromboses (DVTs)
• POST OPERATIVE DAY 3 TO 5

• Patients at high risk for developing postoperative DVT include those
undergoing
 abdominal-pelvic surgery or
 lower extremity orthopedic surgery,
 patients with major trauma or spinal cord injury,
 patients with cancer, and
 those who are obese

• Patients also can have a febrile response to a pulmonary embolism (PE)
without signs or symptoms of a DVT. PE can be a cause of sudden death in
a postoperative patient.
• Patients with suspected DVT should be screened with a lower extremity
Doppler ultrasound and started on therapeutic anticoagulation when
clinically safe

WONDER DRUG
• Medications are the most common noninfectious cause of fever in
postoperative patients
• Antimicrobials and heparin account for almost one-third of cases of drug-
related fever in hospitalized patients.
• Antimicrobial – Vancomycin and beta lactams
• Anticonvulsant – phenytoin
• OCCUR AT ANY POST OPERATIVE PERIOD

WONDER DRUG
• Serotonin syndrome
• is caused by medications interacting with selective serotonin
reuptake inhibitors (SSRIs)
• resulting in increased serotonergic neurotransmission and
overstimulation of central and peripheral serotonin receptors.
• Signs and symptoms of serotonin syndrome include
 fever,
 altered mental status,
 hyperreflexia,
 myoclonus, and
 mydriasis.

WONDER DRUG
• Malignant hyperthermia,
• which occurs in genetically susceptible patients when they are
exposed to volatile anesthetics, causes profound calcium
accumulation  intense muscle contraction  cellular
hypermetabolism.
• Can be delayed in onset upto 24 hours in immunocompromise pt
• Symptoms include
 muscle rigidity
 acid-base disturbances
 hyperthermia

WONDER DRUG
• Neuroleptic malignant syndrome
• It is a dysautonomic condition thought to be caused by dopamine
receptor blockade in the hypothalamus that
• Symtpoms
 muscle rigidity,
 altered mental status, and
 hyperthermia.
• Most commonly caused by the typical neuroleptic medications
• it also can be caused by antiemetic medications such as
metoclopramide and promethazine that are commonly used to
manage postanesthesia nausea

WONDER DRUG
Other drug mechanism
• Infusion site inflamation (phlebitis,
sterile abscess, soft tissue reaction)
amphoterecin B,
erythromycin,
KCL
• Stimulate heat production
Thyroxin
• Limit heat dissipation
Atropine,
epinephrine
• Alter thermoregulaltion
Butyrophenone tranquilizer,
phenothiazide,
antihistaminic,
antiparkinson

WITHDRAWAL (ALCOHOL)
• Typically are mild with vague complaints
 insomnia,
 anxiety,
 headache, and
 diaphoresis.
• These symptoms can easily be overlooked or misinterpreted as
normal postoperative manifestations.

• If patients are not identified and treated, they may develop delirium
tremens.
• Delirium tremor
• mortality of up to 4%,
• begins about 72 hours after the last alcohol ingestion.
• Clinical features
 hyperthermia (temperature greater than 40° C),
 altered mental status,
 agitation,
 hallucinations, or
 seizures

• The acute treatment
 aggressive high-dose benzodiazepine regimen, either diazepam or
lorazepam, until symptoms resolve
 medications are then tapered over the next several days.

WONKY GLAND
• Two endocrinologic causes of fever in postoperative patients -
1. adrenal insufficiency and
2. Thyrotoxicosis

WONKY GLAND
• Adrenal insufficiency
 hypotension
 hyponatremia
 hyperkalemia
 hypoglysemia
 fever
• Management of acute adrenal crisis
a bolus dose of glucocorticoids with either dexamethasone 4 mg IV or
hydrocortisone 100 mg IV +
crystalloid volume +
resuscitation glycemia and unexplained fever

WONKY GLAND
• Thyrotoxicosis
 tachycardia
 altered mental status
 hyper- or hypotension
 hyperthermia (greater than 40° C)
• Acute management of thyroid storm
beta-adrenergic blockade (propranolol 1 mg IV bolus) +
thionamide (propylthiouracil 200 mg oral) +
iodine solutions.

Approach to post operative fever
accourding to post-operative
duration

POD 1-2 (24 to 48 hour = 1st day fever)
• Mc cause – atelectasis
• Persistent infection
• Rare
 Transfusion reaction
 Thyroid crisis
 Malignant hyperthermia
 Drug fever

POD 3-4 (48 to 72 hour = 3rd day fever)
• Infection related to indwelling device
 Cystitis, UTI
 Sinusitis
 Drip site infection – phlebitis
• DVT and PE
• Hematoma
• Gout
• Tissue necrosis

POD 5 to 8
• Wound infection
• Intra-abdominal abscess
• Anastomosis leaked
• Rare
 Antibiotic induces colitis
 Acalculous cholecystitis

Post operative fever

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