Post-operative fever
Leanne Wood
R6
General Surgery
Outline
• Case Review
– Define post-operative fever
– DDx of post-operative fever
– Principals of management and treatment of
post-operative fever
CASE
ID
44 yr female with epigastric pain, seen
in Peach Arch Hospital
HPI About 3 week Hx of low grade
epigastric pain, increased on day of
presentation, associated with nausea
and decreased appetite.
CASE
Past Md Hx
None
Meds
None
Allergies
None
ROS
No wt loss, no fevers, no
jaundice, no smoking, no
ETOH
CASE
O/E Increased BMI, soft abdomen with no
mases or organomegaly but mild
tenderness in epigastrum
ER physician ordered some basic
blood work:
WBC 5.0, Hg 114, lytes/BUN/crt all N
amylase 292, other LFT/bili/INR all N
CASE
U/S No cholelithiasis, no bile duct dilation
A complex solid and cystic mass in
neck of pancreas measuring 53 X 46 X
37 mm
CASE
CT Scan
mixed solid/cystic mass at junction of the
neck/body (4.3 X 3.6 X 4.4 cm)
no hypervascularity, no calcification
pancreatic duct dilated all the way to the tail
(4.5 cm)
SV/SMV confluence compressed but no
thrombosis or invasion
CASE
The patient was referred to Dr. Scudamore
Initially Dr. Scudamore was going to do an
ERCP, but since the lesion appeared
resectable and the patient was a good
operative candidate, she went directly to
the OR
CASE
She had a distal pancreatectomy
The splenic artery and vein were ligated,
but the spleen was not removed
CASE
POST-OP
• CVL
• PIV
• Foley
• PICRA
• 2 HMV drains
POD #1
• 378, 120/75, 120, 16, 100% on 4L NP
Does she have a fever?
Fever
Any body temperature over 378
Are you concerned?
What do you want to do?
Fever
• 1/3 of post-operative patients will get fevers
• The timing of the fever and associated
symptoms are important factors to consider
– Early: “atelectasis”, inflammatory response, drugs
– Late: infections (superficial or deep SSI, pneumonia,
UTI, vascular access lines), thrombosis
• A “shot gun” approach is probably not beneficial
– The so-called “septic work-up”
•A chart review of patients undergoing gynaecologic surgery
•Selected patients who developed post-operative fever
•>38.0 on two occasions within 8 hrs of each measurement
•Repeated analysis for temp >38.5
•Sought to determine the usefulness and cost-effectiveness of “routine
septic work up”
Results
• 28.9% of patients had fever
• Of those, 64% had temp ≥38.5
• Of those with fever, 61% had at least one lab or
radiologic test
• Of those tests, only 17% were positive
• Residents evaluated 30% of these patients at the time of
their fever
• 55% of patients who received an investigation were not
evaluated at the time of their fever
• Of the patients evaluated at the time of their fever, the
history and physical exam did not direct investigations
59% of the time and a rote work up was performed
Results
• Overall cost for testing was $48,432
– $2,201 per serious infection
Conclusion?
POD #1
• WBC 12.8 (neu not done)
• No cough, no SOB, no leg pain, dressing
dry, abdo soft
• Advanced along expected post-operative
course
– Sips CF, mobilize to chair, check labs
POD#2
•
•
•
•
377, 115/70, 100, 16, 100% on 4L NP
WBC 13.5
Hg 77 down to 55?!
No clinical signs of bleeding
– Such as……?
• Repeat Hg (77) but also gave 1 unit PRBC
POD #2
• 382
Dose she have fever ?
What do you want to do?
POD#2
• Could be from the transfusion
• Decision to continue transfusion, give
Tylenol for comfort
– What if she were NPO?
POD #3 (very early)
• On call team called for temp 392
What do you want to do?
POD #3
• On call team ordered blood cultures
POD #3 (team rounds at 0630)
• 392, 170/90, 100, 20, 99% on 3 L NP
• WBC 17.9 (neu 14.2)
• Still no cough, tolerating sips CF, hardly
mobilizing
• Ordered urine micro and C&S, CXR
Any other actions?
POD # 3
• D/C CVL, PICRA
• Checked her amylase and the amylase in
the drains
– Amylase 26, and in drains was 177 and 180
• D/C HMV
• Mobilize!!
What do you see?
What do you want to do?
POD #4
• T max 372, 120/80, 90, 20, 97% 2 L NP
• Abdo pain only when moving, taking FF
with no nausea or vomiting, passing gas,
no cough, mobilizing more
• WBC 12.3
What do you want to do?
POD #4
• Follow up on blood and urine cultures
– Both negative at 24 hrs
• D/C foley
• D/C last HMV
• MOBILIZE!
POD #5
• T max 38, 140/80, 100, 18, 98% 2L NP
Dose she have fever ?
What do you want to do?
POD #5
• No cough, urinating freely, wound looks
healthy, had a BM, abdo soft and not
distended, PIV site OK
What do you want to do?
POD #5
•
•
•
•
WBC 13.1 (neu 8.3) other labs N
Cultures still negative
Encourage mobilization
Try to wean oxygen
POD #6
• T max 382, 150/85, 95, 98% on 2L NP
Dose she have fever ?
What do you want to do?
POD #6
• WBC 15.9 (neu 10.2)
• Previous cultures still neg
What do you want to do?
What do you see?
What do you see?
Case Wrap-up
•
•
•
•
LLL effusion and atelectasis
Evolving splenic infarct
No fluid or abscess in the abdomen
Improved clinically
– T max intermittently 38, weaned from oxygen,
mobilizing, eating
• WBC continued to rise to 30!
WHY?
Post-op fever: Summary
• It is important to evaluate the patient with a history and
physical exam and order investigations appropriately
– **routine septic work up is not cost-effective**
• Be in tune to the unique circumstances of the patient
–
–
–
–
–
Dirty wound
Intra-op blood transfusions
Length of OR time
Hypoxemia
Hypothermia
Post-op fever: Summary
• Put the fever in context
– Other signs of sepsis or respiratory distress (BP, HR,
U/O, sats)
– Timing of fever
• Number of days post-op
• Recurrent or sustained
– Associated WBC
– Associated symptoms and signs
Thank You!