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

CASECT 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!