Post Operative Fever
Postoperative Fever
Tad Kim, M.D.
Connie Lee, M.D.
Michael Hong, M.D.
Kenny DeSart, M.D.
Post Operative Fever
Pathophysiology
• Fever >38ºC is common after surgery
• Most early postoperative fever is caused by the
inflammatory stimulus of surgery and resolves
spontaneously
• Fever = response to cytokine release
– Fever-associated cytokines are released by tissue
trauma and do not necessarily signal infection
– Cytokines produced by monocyte, macrophages,
endothelial cells
– Fever-associated cytokines = IL-1, IL-6, TNF-alpha,
IFN-gamma
Post Operative Fever
DDX: The 5 W’s
1.
2.
3.
4.
5.
Wind (POD#1)
Atelectasis, pneumonia
Water (POD#3)
UTI, anastomotic leak
Wound (POD#5)
Wound infection, abscess
Walking (POD#7)
DVT / PE
Wonder-drug or What did we do?
Post Operative Fever
DDX: Immediate Fever
• Immediate fever: onset in OR or in the immediate
postoperative period
– Go look at the wound
• DDX:
– Medication reactions: antibiotics, blood products,
malignant hyperthermia. Often p/w hypotension.
– Necrotizing infection: Clostridium, Group A β-hemo
strep. Treatment: ABC, resuscitate, ABX: pip/tazo
and clindamycin, surgical debridement
Post Operative Fever
DDX: Fever
• DDX:
– Necrotizing infection (within 48hrs)
– Anastomotic leak (classically POD# 3 to 5)
– Pulmonary embolism
– Pneumonia/Aspiration
– UTI
– Surgical site infection (SSI)
– Deep abscess
– ETOH withdrawal
– Clostridium difficile colitis
– CVL infection
– Other: acute gout, pancreatitis
Post Operative Fever
Evaluation
• ABCs
• Resuscitate
• HPI: anesthesia record, operative note, nursing report,
flowchart
• PE:
– Complete exam
– Look at wounds - take off dressings
– Look at drain output
– Check PIV sites, CVL, Foley, tubes
Post Operative Fever
Labs/Studies
• Labs to order if concerned for infection:
– CBC w diff, sputum Cx, UCx, Blood Cx x2
– Lumbar puncture (if AMS, neck pain, fever-rarely
ordered)
– C. diff toxin assay from stool
• Imaging:
– CXR (for pneumonia)
– Lower extremity venous duplex (for DVT)
– CT scan (for abscess, leak, pancreatitis, PE)
• Usually wait until POD5
– RUQ ultrasound (for cholecystitis)
Post Operative Fever
Management
• Remove/replace sources of infection
– Foley catheter, central lines, or peripheral
IV’s
– Open, debride, and drain infected wounds
• Antibiotics typically not prescribed for
superficial wound infection
• If suspect pneumonia, bacteremia, UTI,
sepsis – start broad spectrum antibiotics
• Anticoagulation for DVT/PE
• CT guided drainage of abscess
Post Operative Fever
Case 1
• 58y M 5hrs after B/L total knee arthroplasty. Temp
38.7 C. Pain adequately controlled w/meds. No
antibiotics.
• PE: HR 90, BP 130/70, O2 sat: 99%
– Mild serosanguinous drainage from knees
– No Foley or CVL
– WBC 7
• What is your plan?
Post Operative Fever
Case 1
• What is your plan?
– A. Urine culture
– B. Blood, urine cultures & CXR
– C. Blood, urine cultures & vancomycin
– D. Observation only
Post Operative Fever
Case 2
• 65y F w/ obesity, DM now 5hrs s/p open
cholecystectomy for gangrenous cholecystitis c/o
abdominal pain. Temp 40C, tachycardia.
• VW: HR 140, BP 88/50, O2 Sat 94%
• PE: AMS, wound is blistered, +crepitus, w/ dirty
dishwater drainage
• What is your diagnosis?
• What is your plan?
Post Operative Fever
Case 2
•
•
What is your diagnosis?
A. Cellulitis
B. Diffuse peritonitis
This patient is in septic shock
C. Necrotizing fasciitis
D. Uncomplicated post operative fever
What is your plan?
A. Observe
B. ABC, resuscitate, IV antibiotics
C. ABC, resuscitate, IV antibiotics, immediate
surgical debridement
Post Operative Fever
Case 3
• 61y F w rheumatoid arthritis on methotrexate
undergoes left total hip replacement. Foley
catheter present postoperatively. POD#1 temp
38.1C, Foley is removed. POD#4 temp 38.5 C.
• She has been ambulating and using incentive
spirometry
• PE: O2 Sats and vitals are normal, wound is clean
What is the diagnosis?
What is the plan?
Post Operative Fever
Case 3
• What is the most likely diagnosis?
– A. Deep venous thrombosis
– B. Urinary tract infection
– C. Superficial wound infection
– D. Prosthesis infection
• UTI evaluation: history, U/A, urine culture
• Evaluate for other possibilities
Post Operative Fever
Take Home Points
•
•
•
•
•
The 5 W’s
Think the worst and rule it out!
Must correlate clinically
USE COMMON SENSE!!!
Necrotizing fasciitis must be identified and
treated aggressively