Post Op Fever

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Focus on CME at theUniversity of Manitoba

The Canadian Journal of CME / May 2004 93

Christopher Sikora, BSc, MSc; John M. Embil, MD, FRCPCPresented at Bug Day 2003, Health Sciences Centre, Winnipeg (October 2003).

Fever in the Post-operative Patient: A Chilling Problem

Fever may be present in the post-operative peri-od for both infectious and non-infectious rea-sons. It is important not to overlook the non-infec-

tious causes when a fever is present, as the causemay be quite benign, or may be indicative of a seri-ous underlying process. Neoplasms or collagenvascular diseases account for many underlyingfevers. An infectious process is present in less thanhalf of febrile post-operative patients. 1 General

causes of fever in the post-operative period can beclassified in three categories (Table 1).

What are the common causes?The classic 5W mnemonic forremembering the causes of fever in

the post-operative period is W ind, W ater,W ound, W eins/ W ings, and W onder Drugs.These five causes are also time-dependentand are likely to occur in a relatively pre-dictable sequence (Table 2).

Andys Pain

Andy, 72, presents to theemergency department withabdominal pain, nausea, andvomiting. A small bowelobstruction is confirmed bylaparotomy. On the secondpost-operative day, he developspain in and around the incision,associated generalized malaise,and a fever of 38.8 C. Figure 1 demonstrates hisabdomen at the time the fever was detected. He isdiagnosed with a superficial wound infection andempiric antibiotic therapy is started. Staphylococcus aureus is recovered from the wound.

For a followup on Andy, go to page 97.

Angelas RecoveryAngela, 67, is recoveringuneventfully in hospital from abladder suspension p rocedure.On the third post-operative day,she develops a sudden fever of39.4 C with violent vigors. Shehas associated sweats andgeneralized malaise. A septicworkup, consisting of a fullhistory and physicalexamination, reveals discomfort in the left antecubitalfossa where a large bore intravenous catheter hadbeen placed during the surgery. Upon furtherinspection, it is possible to milk pus from the catheterinsertion site (Figures 2a and 2b). Subsequent bloodand urine cultures yielded Staphylococcus aureus .

For a followup on Angela, go to page 97.

I n the first 24 hours after an operation,27-58% of patients may develop fever.


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Fever

Wind

In the first 24 hours after an operation, 27%to 58% of patients may develop fever. Most

of these cases, which are likely due to atelec-

tasis, are of little concern unless associatedwith systemic signs, such as rigors, alteredmentation, or hypotension. Pneumonia mayoccur several days post-surgery and is animportant diagnosis to consider if systemicsigns are present; it is also important toquestion the presence of a ventilator-associ-ated pneumonia after prolonged intubation.

Water

The patient has an increased risk of developingcystitis the longer a urethral catheter is in place.The catheter should be removed as soon as thepatient is able to mobilize, or use a urinal.

Wound

It is important not to miss something nefarious,like a necrotizing fasciitis or an intestinal leak,

especially post-surgery. A cellulitis may be present

Doris DiscomfortDoris, 63, presents feelinggenerally unwell. A diffuseabdominal discomfort wascorroborated by her daughter,who noted her mother hadcomplained of left flank painand urinary hesitancy, urgency,and dysuria. A more extensivehistory revealed that

approximately one week prior,the patient had been discharged from hospital afterhaving undergone an open cholecystectomy, whichwas originally planned to be completedlaparoscopically.

The abdominal examination was unremarkable andleft flank tenderness was present on percussion. Aurine specimen was ob tained, which was turbid, andthe urine dipstick indicated many leukocytes andnitrates. An empiric diagnosis of a urinary tractinfection (UTI) was made and oral antibiotics initiated.Urine cultures returned Escherichia coli to aconcentration of greater than 10 8 cfu/L.

For more on Doris, go to page 97.

Table1Infectious and non-infectiouscauses of fever in thepost-operative patient

InfectiousSurgery

Wound infection

Intra-abdominal abscess

Leaking anastomosis with peritonitis

Infected prosthetic material Acute cholecystitis

Transfusion-related infection

Pheochromocytoma

InfectiousNot Surgery Related

Pneumonia

Urinary tract infection

Infected hematoma

Systemic bacteremia

Clostridium difficile enterocolotis

Pharyngitis

Relatednon-infectious

Atelectasis

Medications (anesthesia or other)

Thrombophlebitis

Adrenal insufficiency

Drug fever

Malignancy

Pulmonary embolus

Deep vein thrombosis

Myocardial infarction

Thyrotoxicosis

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in the early stages of post-surgery and an abscessmay evolve. In late stages, prosthetic material maybe infected and present itself as a fever. Leakinganastomosis, from gastrointestinal procedures,may also be present later on.

Weins/WingsVeins, extremeties and all vascular accesssites should be inspected for the presence of thrombophlebitis. Likewise, it is importantto consider a deep vein thrombosis in apatient who has been immobilized, or hasanother reason to be in a hypercoagulablestate.

Wonder drugs

Always consider the patients previous med-ications, as well as those received intra-operatively, as possible causes of fever. Anytransfusion products or anti-inflammatory

agents can be included in this category. 2

Table2Causes of fever according to time of onset

Day OneLocal causes

Atelectasis

Wound cellulitis


Indwelling catheter infection

Transfusion reaction

Drug fever

Thrombophlebitis

Surgical complications

Day TwoRespiratory/Catheter causes

Pneumonia


Wound cellulitis

Necrotizing fasciitis or clostridial myositis

Day ThreeSystemic causes

Thrombophlebitis

Deep vein thrombosis

Wound infection

Cholecystitis

Pancreatitis

Systemic bacteremia/fungemia/viremia

Day Seven and onSurgical complications,undiagnosed disease

Leaking anastomosis

Infected prosthetic material

Deep wound infection

Abscess

Deep vein thrombosis or thrombophlebitis

Clostridium difficile diarrhea

Collagen/Vascular disease

Occult bacteremia

Neoplasm

Mr. Sikora is a senior medical student at theUniversity of Manitoba, Winnipeg, Manitoba.

Dr. Embil is a consultant, infectious diseases,University of Manitoba, medical director, InfectionProvention and Control Program, Winnipeg RegionalHealth Authority, and director, Infection Preventionand Control Unit, Health Sciences Centre,Winnipeg, Manitoba.


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Evaluating a patient with post- operative fever

It is important to elicit the timeline associatedwith the fever. Key questions to ask are: When was the surgery? What type of procedure was performed? Are there pre-existing or implanted

prostheses involved? What and when was peri-operative antibiot-

ic prophylaxis given? When did symptoms begin? Were any symptoms present prior to

surgery? Were there any complications with the

surgery, or a prolonged hospital stay? Does the patient have pre-existing medical

conditions that could predispose to fever? Were there blood products given?

A thorough review of systems, including res-piratory, genitourinary, gastrointestinal, neuro-logic, and cardiac is necessary. Physical exami-nation should include the respiratory, cardio-vascular, urinary, and gastrointestinal systems,as well as a thorough examination of the skin.

An examination of the peripheral or central

sites that were used for vascular access is alsoimportant, as an infected hematoma or throm-bophlebitic vein may be present.

Lastly, a thorough inspection of the woundsite is imperative. Is there a fluctuant mass palpable? Is redness or heat present surrounding the

incision? Is there a surrounding wound cellulitis

that may or may not be well demarcated?

Is pain present?

Figure 1. Abdominal wall cellulites in our patient. Figure 2a. Medial to the intravenous catheter is a superficialcollection of pus, which was expressed from the underlyingseptic vein.

Figure 2b. Once this site is cleaned, a large opening of the septicunderlying vein can be observed.


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Does the implanted joint have full range of motion?

It is important to always consider a latent infec-tion in neurosurgical, orthopedic, and cardiacprocedures. A thorough review of the patient'smedications is prudent, as it is important not tooverlook a drug fever associated with thecommencement of a new medication.Antibiotics themselves may lead to drug feversand should not be started unless absolutely nec-essary. It is also important to remember thatantibiotics may cause Clostridium difficile -associated disease, which may manifest withfever, abdominal pain, and diarrhea.

Applicable laboratory tests are outlined in

Table 3. An abdominal computed axial tomo-

graphic scan may be of benefit if abdominalsurgery or an intra-abdominal process isanticipated. Nuclear medicine scans mayhelp in detecting local inflammatoryprocesses; however, prior to their request, it

Returning to DorisDoris presented with a UTI likely from theurinary catheter inserted during surgery. E. coli was recovered from her urine and an ultrasoundof her kidneys revealed findings compatiblewith pyelonephritis on the left side. Since shewas clinically stable, she was provided oralciprofloxacin and had an uneventful recovery.

Revisiting AngelaAngela presented with S. aureus bacteremiaarising from the insertion of the intravenouscannula required for administering theanesthetic. S. aureus bacteremia is a seriousoccurrence and cannot be ignored. It can leadto metastatic foci of infection, such asosteomyelitis, septic joints, and endocarditis.The standard management procedure involves

the removal of the endovascular device and twoweeks of parenteral therapy. Angelashospitalization was significantly complicated bythe S. aureus bacteremia, which was eventuallycleared after two weeks of cloxacillin treatment.

Andys FollowupAndy presented with a superficial skin and softtissue infection arising directly from the incisionsite. It is possible that micro-organisms presenton the skin at the time the original incision wasmade were inoculated into the surgical site. Thispatient received several days of parenteralantimicrobial therapy and was then dischargedhome on oral antibiotics with a completeresolution of his infection.

Table 3

Applicable laboratory tests

Urinalysis

Complete blood count with differential andperipheral smear

Erythrocyte sedimentation rate

Blood cultures

Radiographic imaging

Altace


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may be prudent to discuss the scans role in themanagement of the patient. 3

What treatments are available?

Treatments for the post-operative fever are all dependenton the etiology. Thus, identifying the likely causethrough a thorough patient history and physical exami-nation becomes critical. Atelectasis will improve with

time, although incentive spirometer may speed theprocess. Removing the offending invasive device andtreating the infection with appropriate antibiotics solvescatheter-related infections. Thrombophlebitis can oftenbe treated with warm compresses and anti-inflammatoryagents, however, if signs and symptoms of infection arepresent, appropriate antibiotics must be used.

References1. Howard RJ: Finding the cause of postoperative fever. Postgraduate

Medicine 1989; 85:223-38.2. Kamal A, Kauffman CA: Fever of unknown origin. Prograduate Medicine

2003; 114:69-76.3. Mourad O, Palda V, Detsky AS: A comprehensive evidence-based approach

to fever of unknown origin.Arch Intern Med 2003; 163:545-551.

CME

Fever can appear for both infectious andnon-infectious reasons after an operation.

In the first 24 hours after operation, 27% to 58%of patients may develop fever.

Physical examination should include therespiratory, cardiovascular, urinary, and

gastrointestinal systems, as well as anexamination of the skin.

Thrombophlebitis can often be t reated with warmcompresses and anti-inflammatory agents.

Take-homemessage

w w w . s t a c o m m u n i c a t io n s . c o m

For an electronic version ofthis article, visit:The Canadian Journal of CME online.

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