Victoria HallIntern

The page.....“Mr Jones in 3SW Bed 44 has just spiked a

fever. Please review....”

What do you want to know over the phone?

What do you want to know over the phone? Clarify what “fever” is – what was the

recorded temperature? How long have they had the temperature for?What are their other vital signs?What day post-op is the patient?What was the reason for admission/ what

surgery did they have? Are they able to help you out and start taking

bloods?

The reply...“Not really sure how long they have had the

fever for. He was admitted the other day, I think his surgery was three days ago. He doesn’t look himself. His family are worried actually....His temperature is 38.1, BP 105/60, HR 90, RR 20. I’ll see what I can do about the bloods...”

And in your mind...

And in your mind...How sick is this patient?Do they need urgent review

(haemodynamically unstable/are they met call criteria?)

After your review - does the surgical registrar need to know about this patient/do you need help?

What classifies as fever?

Rectal temperature > 38ºCOral temperature > 37.8ºCAxillary temperature >37.2ºCTympanic membrane temperature > 37.5ºC

Beware of the elderly patients “the older the colder”, and immuno-suppressed

What is the mechanism behind fever?Manifestation of cytokine release in response to a

number of stimuliIL-1, IL-6, TNF-alpha, IFN-gammaSome evidence that IL-6 is most closely correlated with

post-operative feverFever-associated cytokines are released by tissue traumaThe magnitude of the trauma : degree of the fever

responseBacterial endotoxins and exotoxins translocated from the

colon can stimulate cytokine release and cause postoperative fever

NSAIDs and glucocorticoids suppress cytokine release and thereby reduce the magnitude of the febrile response

Systemic Inflammatory Response SyndromeSIRS is the clinical syndrome that results from a

dysregulated inflammatory response to a non-infectious insult, such as an autoimmune disorder, pancreatitis, vasculitis, thromboembolism, burns, or surgery.

Two or more of the following be present:Temperature >38.3ºC or <36ºCHeart rate >90 beats/minRespiratory rate >20 breaths/min or PaCO2 <32

mmHgWBC >12,000 cells/mm3, <4000 cells/mm3, or

>10 percent immature (band) forms

What day post op is the patient?Day 1-2: unlikely to be an infection, often

related to inflammatory stimulus of surgeryDay 2 -7 : nosocomial infections – pneumonia

(ventilator associated or aspiration), urinary tract infection, intra-vascular catheters, non-infectious causes

Day 7 +: wound infection, antibiotic-associated diarrhoea (ie C.Difficile)

Delayed (often discharged home): wound infection, implanted medical devices, infective endocarditis

Atelectasis as a CAUSE of fever?Both occur frequently after surgeryTheir concurrence is probably coincidental

rather than causal Studies of abdominal surgery patients have

found that there was no association between fever and the presence of, or the degree of, atelectasis [73].

Fever does not always mean infection!What are the non-infectious causes of acute

fever in the surgical patient?

Non-infectious causes of fever...P.E.DVTPancreatitisMyocardial infarctionAcute goutAlcohol withdrawalIatrogenic: medications (antibiotics, heparin),

transfusion reaction, drug-drug interactions (ie serotonin syndrome)

Approach to the febrile surgical patientQuick bedside “look” test – are they well or

unwell? What are their vital signs? Is it actually a

fever?Are they haemo-dynamically stable? What is their RR (measure it yourself...)?Have they had previous fevers? What is the

trend?

Approach to the febrile surgical patientTake a history! What do you want to know?Keep an open mind Read through their inpatient notes, look at

their medication charts – are they on antibiotics? Were they previously on antibiotics?

History...History of the fever, associated chills or rigors?Malaise, lethargy, decreased exercise toleranceAssociated symptoms...Chest: cough, sputum, dyspnoea,

haemoptysis, wheeze, pleuritic chest painMeningism: neck stiffness, photophobia,

headache, seizureUrinary: dysuria, haematuria, frequencyAbdominal: pain, nausea, vomiting,

diarrhoea, ileus

History...Wound/IVC: tender, erythema, purulent

discharge, wound breakdownSkin: rash, splinter haemorrhagesJoint exam: red, swollen joint, tender,

decreased ROM/mobility, painMental state – are they able to give you a

history? Are they in a delirium? (and could this be the cause?)

History...Other clues...What was the reason for admission?Are they immuno-compromised? Is the

patient a diabetic?Any exotic travel recently?Have they received DVT prophylaxis whilst

an inpatient? Has it been administered?What is their risk for PE? What medications are they on? Could this be

a drug fever?

Approach to the febrile surgical patientThorough examination – you are looking for

clues/source of the fever...Including bedside tests – ECG, urine dipstick

On Examination...Use the history to guide youA,B, CLook for signs of shock: mental state,

peripheries / capillary refill, hourly urine output

RashIV access sitesSurgical wound(s)/biopsy siteDo they have a catheter in? What colour

urine is it draining?

On Examination...Proper physical examination: Cardio-

respiratory, abdominal, neurological, joint – what are you looking for?

Tender calves? Blood transfusion?

What investigations do you need to perform?Be guided by history and examinationI’m going to order a “full septic screen”...And other tests?

Investigations...Bloods: FBE, UEC, CRP, Coagulation profile,

Blood cultures +/- LP for CSF analysisBSL ABGUrine dipstick + MCSWound swabCatheter tip/ IVC tipCXRECG? CTPA (consider it!)Others for non-infectious causes

ManagementIn any acute situation - always remember

ABCIf they are unwell and you are worried – tell

someone! Good documentation = good doctor

ManagementABCA: patent, no obstruction evident, speaking in

full sentences B: keep SaO2 >90%, (CO2 retainers 88-92%),

ABG can give answers!C: If hypotensive -> wide bore IV access,

fluid bolus (watch for the patient with CCF)D: What is their GCS? Are they at risk of

airway collapse? Are they delirious? Remember BSL...

ManagementBe guided by your likely diagnosisRemove offending treatment – ie medications

causing drug fever, IDC, intra-vascular access sites...

Regular paracetamol will provide comfort and minimise physiologic stress of fever

If you suspect infection...Be guided by Surviving Sepsis Campaign: Early resuscitation and antibioticsIsolates before antibiotics (which means 2 sets of

blood cultures separated in time and place)Strong recommendation for crystalloid as initial fluid

resuscitation (1L or more) – and watch for responseWeak recommendation for albumin with crystalloid

for severe sepsis and septic shock Usually broad spectrum antibiotics, appropriate to

suspected source of infection – within one hour of diagnosis of septic shock or severe sepsis without shock

Narrow spectrum once microbiology results become available

Which antibiotic?Often difficult decisionUse local hospital guidelines/clinician

preference for recommended antibioticsThink about what you are targeting, previous

antibiotic exposure, immuno-competency of the patient and how severe the infection is

ManagementReview, review, review The patient and their results Are they improving or getting worse?Have they responded to your fluid challenge?Do you need to re-think your initial

diagnosis?Handover!

Any questions?

References Weed HG, Baddour LM, Up To Date 2012,

Postoperative fever. Viewed Oct 8 2012. Available at URL www.uptodate.com

Neviere R, Up To Date 2012. Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis. Viewed Oct 8 2012. Available at URL www.uptodate.com

Cadogan M, Brown FT, Celenza T, 2011, Marshall and Ruedy’s On Call – Principles and Protocols, 2nd Edition, Saunders Australia.

Surviving Sepsis Campaign 2008, Surviving Sepsis Campaign Guidelines. Viewed Oct 8 2012. Available at URL: http://www.survivingsepsis.org/Pages/default.aspx