Transcript Postoperative Fever

Postoperative Fever
Postoperative fever occurs in up to two thirds of patients, and
infection is the cause of fever in one third of cases.
Absent a fever, any hypotension, tachycardia, tachypnea,
confusion, rigors, skin lesions, respiratory manifestations,
oliguria, lactic acidosis, leukocytosis, leukopenia, immature
neutrophils (i.e., bands >10%), or thrombocytopenia may indicate
a workup for infection and immediate empirical therapy.
Postoperative Fever
Some infected patients do not become febrile and may be even be
hypothermic. Hypothermic or euthermic patients may have a lifethreatening infection. These include older patients, those with
open abdominal wounds, or with ESLD or CRF, and patients
taking anti-inflammatory or antipyretic drugs.
Fever, may have an noninfectious cause; therefore, fever does not
equate with infection.
Postoperative Fever
Fever is common during the initial 72 hours following surgery and
is usually noninfectious in origin (DVT, PTE, tissue ischemia or
necrosis, adrenal insufficiency, drug fever, malignant
hyperthermia, and acute allograft rejection).
Postoperative Fever
Immediate —onset in the operating suite or within hours after
surgery
Medications or blood products; trauma suffered prior to surgery or
as part of surgery; infections that were present prior to surgery;
and rarely malignant hyperthermia.
Drug fever is decidedly unusual in surgical patients and is a
diagnosis of exclusion.
Drug fever in surgical ICUs is most often attributed to
antimicrobial agents (e.g., vancomycin, β-lactams), and
anticonvulsants (especially phenytoin).
Postoperative Fever
Immediate —onset in the operating suite or within hours after
surgery
The initial clinical signs (ie, hypercarbia) of malignant
hyperthermia typically present within 30 minutes following the
administration
of
a
triggering
agent
(eg,
inhaled
anesthetics, succinylcholine), but have been reported later in the
operative course and also following cessation of anesthesia.
Fever due to the trauma of surgery usually resolves within two to
three days. Fever caused by severe head trauma can be persistent
and may resolve gradually over days or even weeks.
Postoperative Fever
Acute — onset within the first week after surgery
Nosocomial infections are common during this period.
pneumonia : Ventilation, depressed mental status or gag reflex due
to anesthesia and analgesia
UTI : urethral catheters, GU procedures
Postoperative Fever
Acute — onset within the first week after surgery
SSI most often presents in the subacute period. However,
clostridial or streptococcal SSIs can manifest as fever within the
first 72 hours of surgery.
Catheter exit site infections and bacteremia associated with
intravascular catheters also tend to occur subacutely but should be
considered as sources of fever in any patient with a catheter in
place.
Postoperative Fever
Acute — onset within the first week after surgery
Acute fever can also be caused by noninfectious conditions.
(Pancreatitis, MI, PTE, DVT, alcohol withdrawal, and acute gout).
Postoperative Fever
Subacute — onset from one to four weeks following surgery
DVT, PTE, drug fever (Beta-lactams antibiotics and sulfacontaining products, H2-blockers, procainamide, phenytoin,
heparin), SSIs, nosocomial infections (device-related infections
due to bacteria and fungi include intravascular catheter-related
infection with or without bacteremia, VAP, UTI, sinusitis, AAD,
AAC, )
Postoperative Fever
Delayed — onset more than one month after surgery
Most due to infection
infections from blood products (CMV, hepatitis viruses, HIV,
toxoplasmosis, babesiosis, malariae)
SSIs due to more indolent microorganisms (eg, CoNS)
delayed cellulitis when surgery has disrupted venous or lymphatic
drainage
Infective endocarditis due to perioperative bacteremia
Postoperative Fever
CONSIDERATIONS FOLLOWING SPECIFIC SURGERIES
Cardiothoracic surgery
Neurosurgery
Vascular surgery
Abdominal surgery
Obstetric and gynecologic surgery
Urologic surgery
Orthopedic surgery
Transplantation
Postoperative Fever
CXR, U/A, U/C, B/C are not indicated for all postoperative
patients with fever.
The need for laboratory testing should be determined by the
findings of a careful history and physical examination.
The febrile postoperative
systematically.
patient
should
be
evaluated
In evaluation, type of surgery performed, patient’s immune status,
underlying primary disease process, duration of hospital stay, and
epidemiology of hospital infections should be considered.
Postoperative Fever
Evaluation involves studying the six Ws: wind (lungs), wound,
water (urinary tract), waste (lower GI tract), what did we do?
(medications, blood products, and intravascular, urethral, nasal,
and abdominal catheters) , and walker (e.g., thrombosis).
Postoperative Fever
Urinalysis and culture
Sputum gram stain and culture
* Studies should be ordered based upon the patient evaluation; no test is mandatory to obtain.
Blood culture (from catheters and peripherally - minimum of two)
Wound culture
Complete blood count with differential
Chest radiograph
Additional blood or radiographic studies might be indicated by specific findings. As
examples, abdominal pain might indicate the need for blood tests for hepatic and
pancreatic enzymes or abdominal CT scanning; unilateral leg edema might indicate the
need for ultrasound to rule out DVT.
* Studies should be ordered based upon the patient evaluation; no test is mandatory to obtain.
Studies should be ordered based upon the patient evaluation; no test is
mandatory to obtain.
Postoperative Fever
Any unnecessary treatments, including medications and catheters,
should be discontinued in patients with postoperative fever.
It is probably appropriate to suppress the fever in most patients
with one or two days of scheduled acetaminophen to minimize
patient discomfort and the physiologic stress and metabolic
demands of fever and shivering. This approach is unlikely to mask
a significant pathologic condition.
Additional treatment depends upon the cause of the fever.
Postoperative Fever Rx
Patients who have undergone major surgery and are receiving
intensive care and patients with hemodynamic instability
generally should be treated empirically with broad-spectrum
antibiotics after cultures have been obtained.
Postoperative Fever Empiric Rx
Postoperative Fever
Nosocomial pathogens are often resistant to many antimicrobials;
hospital antibiograms can be useful for selecting an appropriate
broad-spectrum regimen.
If a source of fever is not apparent and blood cultures show no
growth after 48 hours, then discontinuation of antimicrobials
should be seriously considered.
Postoperative Fever
If a site of infection is identified and/or cultures are positive, the
broad-spectrum regimen should be focused to cover the probable
or known causative organism(s).
Antimicrobial treatment beyond the empiric period of 48 hours
should be reserved for patients in whom an infection has been
identified.
Gram stain findings and hospital antibiograms can be used to
guide empiric antimicrobial selection, but definitive treatment
should be based upon antimicrobial susceptibility results from
cultured organisms.
SSIs
SSIs
SSIs
SSIs
In diagnosing SSIs, the physical appearance of the incision
probably provides the most reliable information. Local signs of
pain, swelling, erythema, and purulent drainage are usually
present.
Flat, erythematous changes can occur around or near a surgical
incision during the first week without swelling or wound drainage.
Most resolve without any treatment, including antibiotics. The
cause is unknown but may relate to tape sensitivity or to other
local tissue insult not involving bacteria.
SSIs
Fever or systemic signs during the first several days after surgery
should be followed by direct examination of the wound to rule out
signs suggestive of streptococcal or clostridial infection but
should not otherwise cause further manipulation of the wound.
Patients with an early infection due to streptococci or clostridia
have wound drainage with the responsible organisms present on
Gram stain. WBCs may not be evident in most clostridial and
some early streptococcal infections.
SSIs
A common practice, is to open all infected wounds. If there is
minimal surrounding evidence of invasive infection (< 5 cm of
erythema and induration), and if the patient has minimal systemic
signs of infection (T< 38.5C and PR<1 00 beats/min), antibiotics
are unnecessary. Because incision and drainage of superficial
abscesses rarely causes bacteremia, antibiotics are not needed.
For patients with T > 38.5C or PR> 100, a short course of
antibiotics, usually for a duration of 24–48 h, may be indicated.
The antibiotic choice is usually empirical but can be supported by
findings of Gram stain and results of culture of the wound
contents.
SSIs
SSIs that occur after an operation on the intestinal tract or female
genitalia have a high probability of having a mixed gram-positive
and gram-negative flora with both facultative and anaerobic
organisms.
If the operation was a clean procedure that did not enter the
intestinal or genital tracts, S. aureus (including MRSA) and
streptococcal species are the most common organisms.
Because incisions in the axilla have a significant recovery of
gram-negative organisms and incisions in the perineum have a
higher incidence of gram-negative organisms and anaerobes,
antibiotic choices should be made accordingly.
SSIs
SSIs