General Surgery Rotation

General Surgery: Post-operative fever

Patient will present as → a 52-year-old male underwent a Roux-en-Y gastric bypass surgery (RNYGB) via a laparoscopy. The surgery was uneventful, and the patient is doing well on the floor. However, on the third postoperative day, the nurse has noted the patient has a fever or 101.5°F. The patient has been using his incentive spirometer as instructed. Vital signs are only significant for the fever. Labs show a WBC count of 12,300/mm3. Heart and lungs are clear to auscultation, and the surgical port sites are clean, dry, and intact. Abdomen is soft and nontender. There is mild suprapubic discomfort. Urinalysis shows a bacterial count >100,000 cfu/mL and a WBC of 11 cells/microL. The appropriate antibiotic therapy and catheter management was initiated.

What is the most common cause of fever in the first 48 hours postop?
Atelectasis

Fever caused by cytokines (IL-1. 6, TNF-alpha and interferon-gamma) that occurs postoperatively can be a sign that an infection has ensued. It is important to keep the “5 W's” in mind when considering post-op infection: wind, water, wound, walking and wonder drugs/whopper.

Wind (atelectasis)

  • Post-op fever that occurred in the first 24-48 hours is caused by wind. In the mild form, bronchial breathing may occur. However, in severe cases, ipsilateral tracheal deviation could occur.

Water (UTI)

  • Water or UTI is the most common of post-op infection in the time window of 48-72 hours. It usually results from catheter or GU instrumentation. Pts usually complain of signs of UTI such as frequency, urgency, hesitancy, hematuria or dysuria.
  • UTIs are the MC Nosocomial infections in the hospital.

Wound Infection

  • Post-op fever that occur >72 hours post-op is usually from wound infection. Staph is the MC organism implicated. Infection may be superficial (skin and subcutaneous fat) or deep (involving the areas below the fascia).

Walking (thrombophlebitis): >72 hours post-op

  • Superficial and deep thrombophlebitis can occur. Superficial thrombophlebitis is associated with intravascular catheter while deep thrombophlebitis may be associated with indwelling central line or DVT.

Wonder drugs

  • This usually occurs 1 week post-op. examples of wonder drugs include: anesthetic, sulfa drugs and other.

Whopper

  • This involves the formation of abscesses which can cause an ileus in cases of abdominal abscess. Anastomotic leakage may occur.

Physical exam (look at wound, etc.), CXR, urinalysis, blood cultures, CBC

    • Abdominal CT
    • Cultures (sputum, wound, abscess)

Atelectasis

  • Best treatment is prevention by smoking cessation at least 2 weeks before surgery, use of incentive spirometry.
  • If atelectasis does occur, use of incentive spirometry, mucolytic, expectorants, and inhaled beta-agonists may be beneficial.

UTI

  • Antibiotic therapy should be initiated based on urine culture and sensitivity.
  • Infected indwelling catheters should be removed

DVT

  • Anticoagulant using heparin or LMW heparin.
  • If anticoagulant is contraindicated, can use Greenfield filter for vena cava interruption.

Intraabdominal abscess

  • Percutaneous drainage or surgical debridement with appropriate antibiotic therapy.

Adapted from surgical recall, by Lorne Blackbourne

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