Post-Operative Fever

Post-Operative Fever
Presentation lecture by: Jennifer Caffey, D.O.

HPI
* CC: Fever x 2 days
* HPI: 19 months old female with 2 days history of fever, max. 102F. Emesis x2, described as non-bilious, non-bloody. Appetite decreased but tolerating oral fluids. Good urine output. No sick contacts. Status-post Open Reduction, Internal Fixation 5 days prior to admission for developmental dysplasia of the left hip.

Review of Systems
* No URI symptoms
* No pain in extremities
* No dyspnea
* No chest pain
* No diarrhea, no constipation
* No rashes

Past History

* PMH: developmental dysplasia of left hip
* PSH: 2 prior corrective surgeries on left hip, 1st on May 6, 2nd on May 20, 2004
* Birth: term AGA female born via C-section secondary to hand presentation. Pregnancy complicated by transient episodes of maternal hypotension. Normal nursery stay.
* Previous Hospitalizations: 9 mos for febrile illness. Twice in May 2004 for hip surgery.
* Meds: Tylenol prn fever
* Allergies: NKDA
* Immunizations: UTD by history
* Diet: well rounded, age-appropriate
* Family Hx: Maternal grandmother with Type II DM
* Social Hx: Lives with mom, dad, 5y/o brother and 2m/o brother. Dad is a smoker. + Cats outside. No daycare.
* Developmental: Speaks Spanish only, multiple single words

Physical Exam

* V/S: T 37.3 (ax) HR 145 RR 24 BP: 103/53 Wt: 15kg (>95th)
* Gen: Lying on back in SPICA cast
* HEENT: normocephalic, PERRL, red reflex intact, nares patent, TM’s clear Bilaterally, moist mucosa, oropharynx with mild erythema, no cervical lymphadenopathy
* Heart: regular rhythm, no murmurs
* Lungs: Limited exam secondary to cast, upper lobes clear to auscultation bilaterally
* Abd: Limited secondary to cast, + bowel sounds, lower abdomen soft, not tender
* Ext: lower extremities in cast, lower extremity pulses 2+ and symmetrical
* Neuro: Limited exam, no focal deficits
* GU: normal female genitalia, left hip wound dressed and without drainage.

LABS (initial)
* CBC: WBC 15.6 H/H 8.6/27.2
G 69.5 L 19.6 M 10.4 E 0.2 B 0.2
Platelets 459,000
* Blood Culture -- drawn
* CXR: Lungs are clear except for some increased opacity behind the heart that may represent atelectasis.

Labs during Hospital Stay

* ESR 98 (5/26), repeat 78 (5/28)
* CRP 10.2 (5/26), repeat 2.1 (5/28)
* Blood Culture negative at 73 hours

Differential Diagnosis
* UTI
* Wound infection/abscess
* Pneumonia
* Vascular/venous catheters
* Deep vein thrombophlebitis
* Others…?

Postoperative Fever
* Fever > 38° is common in 1st few days after major surgery
* Most early post-op fever caused by inflammatory stimulus of surgery and resolves spontaneously

* Pathophysiology of fever:
- Fever is manifestation of cytokine release in response to stressful stimuli
- Cytokines released include interleukin-1, TNF-alpha, IFN gamma
- Fever-associated cytokines released by tissue trauma and do not necessarily signal infection
* Timing of fever after surgery is important in establishing differential diagnosis:
- Immediate - onset in operating suite or within hours after surgery
- Acute- onset within 1st week after surgery
- Subacute - onset from 1 to 4 weeks after surgery
- Delayed – onset >1 month after surgery

Post-op Fever- Immediate
Differential Diagnosis:
* Medications or blood products,
* Immune mediated reactions to transfused blood products and antimicrobials, and
* malignant hyperthermia
Fever due to trauma of surgery resolves within 2-3 days (fever due to severe head trauma may be persistent and not resolve for days to weeks)

Post-op Fever- Acute
Differential Diagnosis:
* Nosocomial infections
* Community acquired infections
* Surgical site infection
* Intravascular catheters
* Pneumonia
* UTI

Post-Op Fever- Subacute
Differential Diagnosis:
* Surgical site infection
* Central venous catheter related infections
* Thrombophlebitis
* Antibiotic associated diarrhea
* Drug Fever
* Deep Vein Thrombophlebitis
* Pulmonary Embolism

Post-Op Fever- Delayed
Differential Diagnosis:
* Infection
* Viral infections from blood products
* Surgical site infections

Causes of Post-op Fever
* Infectious:
Surgical site infections
Pneumonia
UTI
Catheter infection
Sinusitis
Meningitis
Parotitis
TSS
* Non-Infectious:
Stress of surgery
Medications
Malignant hyperthermia
Deep vein thrombosis
Fat embolism
Transfusion reactions
Atelectasis?

Orthopedic Procedures
Complications:
Spontaneously resolving fever is the rule after major orthopedic surgery
Differential Diagnosis:
* Surgical Site Infections
* Hematoma
* Deep Vein Thrombosis/Thrombophlebitis

Approach to Patient
* Evaluate patient systemically taking into account timing of onset of fever and the various possible causes
* Initial screen:
* Wind: consider pulmonary causes including pneumonia, aspiration, embolism
* Water: consider UTI
* Wound: consider surgical site infection
* What did we do ?: consider treatment interventions including medications, blood product transfusions, and intravascular, urethral, nasal and abdominal
Treatment

* Remove unnecessary treatments including medications and catheters
* Suppress fever with tylenol
* Antibiotics per clinical judgment/culture results

Post-Operative Fever.ppt