Transcript Investigation and Management of the febrile surgical patient – an

Victoria Hall
Intern
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 > 38ºC
 Oral temperature > 37.8ºC
 Axillary temperature >37.2ºC
 Tympanic 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
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of stimuli
IL-1, IL-6, TNF-alpha, IFN-gamma
Some evidence that IL-6 is most closely correlated with
post-operative fever
Fever-associated cytokines are released by tissue trauma
The magnitude of the trauma : degree of the fever response
Bacterial 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
Syndrome
SIRS 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 <36ºC
 Heart rate >90 beats/min
 Respiratory rate >20 breaths/min or PaCO2 <32 mmHg
 WBC >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 surgery
 Day 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 surgery
 Their 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.
 DVT
 Pancreatitis
 Myocardial infarction
 Acute gout
 Alcohol withdrawal
 Iatrogenic: medications (antibiotics, heparin),
transfusion reaction, drug-drug interactions (ie
serotonin syndrome)
Approach to the febrile surgical
patient
 Quick 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
patient
 Take 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 tolerance
Associated symptoms...
 Chest: cough, sputum, dyspnoea, haemoptysis,
wheeze, pleuritic chest pain
 Meningism: neck stiffness, photophobia, headache,
seizure
 Urinary: dysuria, haematuria, frequency
 Abdominal: pain, nausea, vomiting, diarrhoea, ileus
History...
 Wound/IVC: tender, erythema, purulent discharge,
wound breakdown
 Skin: rash, splinter haemorrhages
 Joint exam: red, swollen joint, tender, decreased
ROM/mobility, pain
 Mental 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
patient
 Thorough examination – you are looking for
clues/source of the fever...
 Including bedside tests – ECG, urine dipstick
On Examination...
 Use the history to guide you
 A,B, C
 Look for signs of shock: mental state, peripheries /
capillary refill, hourly urine output
 Rash
 IV access sites
 Surgical wound(s)/biopsy site
 Do 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 examination
 I’m going to order a “full septic screen”...
 And other tests?
Investigations...
 Bloods: FBE, UEC, CRP, Coagulation profile, Blood cultures
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+/- LP for CSF analysis
BSL
ABG
Urine dipstick + MCS
Wound swab
Catheter tip/ IVC tip
CXR
ECG
? CTPA (consider it!)
Others for non-infectious causes
Management
 In any acute situation - always remember ABC
 If they are unwell and you are worried – tell someone!
 Good documentation = good doctor
Management
 ABC
 A: patent, no obstruction evident, speaking in full
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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...
Management
 Be guided by your likely diagnosis
 Remove 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 antibiotics
 Isolates 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 response
 Weak 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 decision
 Use local hospital guidelines/clinician preference for
recommended antibiotics
 Think about what you are targeting, previous
antibiotic exposure, immuno-competency of the
patient and how severe the infection is
Management
 Review, 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