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DISCUSS THE MANAGEMENT OF POST OPERATIVE PYREXIA.PRESENTER:DR UMAR H.S MODERATOR:DR L.M.D YUSUFOUTLINEINTRODUCTION CLASSIFICATION AETIOPATHOGENESIS MANAGEMENT: RESUSCITATION HISTORY EXAMINATION INVESTIGATION TREATMENT CONCLUSIONINTRODUCTIONDEFINITION: Post-op pyrexia is defined as a rise of the normal core temperature of an individual that exceeds the normal daily variations and in connection wt an increased in the hypothalamic set point following surgery. Temperatures exceeding 38c & >48hrs are clinically significant. Post-op pyrexia common problem after surgery. Occur in 27-58% of surgeries in the 1st 24 hrs. Incidence of infection is less than 10%CLINICAL SCENARIOA 58yr old male. Day 1 post rt hemicolectomy .BP/HR stable.T-38.7C.wcc 11 RX Options: Urine and blood culture. Above and CXR 1 &2 + i.v ABTs Call Registrar Give PCM. ANS:5 NB:Antimalarials in endemic areasCLASSIFICATIONInfective :Surgical & non Surgical Non- infective :atelectasis, drugs, DVT ,malignant hyperthermia(MH) SURGICAL: wound infxn ,intra abdominal abscess, leaking anastomosis with sepsis, infected prosthesis. Non Surgical : malaria, Pn, UTI, pharingitis, systemic bacteraemia .AETIOLOGYUnderlying cause depend on : Time since surgery(5 W). Type of surgery: e.g colon resection, cholecystectomies and laparoscopic. Associated clinical features. 1st 24hrs : Systemic response 2 surgical trauma Pre-existing infxn :UTI, empyema,PID.

PathogenesisRegardless of whether fever is associated with infection, or not , the thermostat is reset in response to endogenous pyrogens, including the cytokines interleukin 1 (IL-1) and IL-6, tumor necrosis factor- (TNF-), and interferon- (IFN-) and IFN-. Setting of body temperature & detection of core T in d preoptic nucleus is by Hypothalamus.

Caused by circulating pyrogens Pyrogens can b Exogenous Gram-negative bacteria endotoxinEndogenous cytokines Culprits are TNF-, INF-, IL-1, and IL-6IL-6 levels correlate logarithmically with post-op peak body temperature

IL-1 is crucial in the febrile response to injured tissue

TNF-, INF-, and IL-6 are pro-inflammatory

SYSTEMIC RESPONSE TO TRAUMAA rise in temp in the 1st 6hrs or the following morning after a surgery ,which maximize on d 2nd day n begin to fall, had been noted in many post op pts. See charts.Temperature Charts

post-op Pyrexia in surgical traumaCuthberston: metabolic changes that occur giving rise to post-op pyrexia . Wilson: acute toxaemia wt a toxin prdtn in damaged tissue leading to pyrexia. CONCLUSION: Pyrexia occur due to either of d two or both.24hrs-72hrsPulmonary atelectasis: impaired cough reflex, hypoventilation etc Chest infection: distruption of natural defensive mechanisms ,hypoventilation ,intubation ,anesthetic agents.3-7dWound infection :skin defence distruptd, duration of surgery, type, and age of pt Anastomotic leak:ischaemia. Intra abdominal abscess; abd. &pelvic surgeries Intra-peritonial-sepsis: operation in septic conditions. UTI: prolong catheterization. Thrombophlebitis: i.v access, damaged endothelium.

7-10dDVT: Veinous stasis, endothelial damage, prolonged immobilization Pulmonary embolism: above in big veins + embolization into pulmonary arteries Prosthetic infection:

NB: malaria can occur anytime post op in endemic areas!Study of post-OP Pyrexia by OHANAKA & CO Surgery department BENIN.7O pts studied post Op ,all had G.A.30 had fever. 11 mps +ve. 1o no surgically related cause. 9 had surgically related causes. The 10 treated wt empirical antimalarials. Responded well. 6 post -OP wt no fever mps +ve. (ENDEMICITY OF MPS)

MANAGEMENTRESUSCITATION:ABCD in life threatening conditions; MH, or wt other post op emergencies. IDENTIFY SOURCE ELIMINATE SOURCE.

HISTORY Indication for surgery. Operation details: duration of op, type of procedure, prophylactic ABTs, blood transfusion, intra-op complications Pre-existing medical conditions & events Inhospitable progress and interventions. Previous hx of pyrexia related to surgeries, or family hx. Use of tobacco, alcohol. Symptoms suggestive of above c0nditions:SYMPTOMS AND SIGNS OF AFFECTED SYSTEMSAtelectesis: cough ,chest pain, .shallow breathing. cyanosis,dim.air entry, dull P.N, dim. air entry, rales.Pneumonia :cough; productive chest , pain, breathlessness. Wound infection: site pain, swelling, redness, purulent discharge ,tenderness.Anastomotic leak: pain localized or generalized, distention.tenderness.guarding,ileus.continuationUTI: dysuria, frequency ,rigors. loin tenderness DVT: silent 2/3rd, swelling of foot ,ankle or calf ,pain ,tender ,warmth, superficial veins PE: massive; collapse &death, cyanosis, severe dyspnoea, pallor, hypotention.EXAMINATIONP.E: Temperature measurement, other physical signs above related to systems affected. Vascular access sites;haematoma. Drains & tubes. Skin & subcutaneous ;abscess ,necrotizing fascitis, gas gangrene. Wound site:fluctuant mass, redness, tenderness discharge. Relevant system as suggested from history.INVESTIGATIONSHaematological: fbc, mps, platelets,E/U/CR,LFT, coagulation profiles wcc : leucocytosis, neutrophylia, toxic granulation. Platelets: increased in stress, decreased in DIC. Hb:decresed in hypodilution. SERUM Biochemistry: e/u/cr deranged in severe sepsis wt renal failure .LFT; deranged in severe sepsis. Arterial blood gases; metabolic acidosis e.g, septic shock. myocardial enzymes ,serum amylasis

CONTINUATIONMicrobiological: blood culture, sputum mcs, pleural & peritoneal aspirates. wound swabs. needle aspiration. stool mcs. csf, catheter tips; urinary & intravascular. Radiologic: CXR; collapsed lung field, effusions, consolidations,subphrenic abscess. ABD uss ;intra abdominal abscess, ileus ,DVT .CT: Abscess .ECG & ECHO: myocardial ischaemia, anomalies of cardiac fxn.23TREATMENTAIM : Reduction of the elevated hypothalamic set point Fascilitate heat loss Reduce oxygen demand. Prevent the aggravation of cardiac, cerebral and pulmonary insufficiencies. Prevent febrile seizures in child. Treating underlying causes identified.GENERAL MEASURESAntipyretics.indicated in T above 39c.Decrease headache,myalgia &arthralgia. Antibiotics:based on sensitive cultured organism or best guess. FLUIDs therapy: hypovolaemia ;septic shock .use vol. expanders;gelatin,dextran +crystalloids. Respiratory support:oxygen therapy. Ionotropes &vaso active agents:systemic infection depress myocardiume.g,adrenaline,dobutamine.Surgical therpyAbscess :open drainage. Elimination of hollow spaces to infections Correction of lesion.Excision of diseased organs:gangrene

conclusionPost-op fever should alert the possibility of an infectn complicating d recovery of the pt. Presence of pyrexia is not a reliable indication of infection and absence is not a guarantee of infection free. The outcome of pt wt post-op pyrexia depend on cause.so detailed ,focused evaluation needed. The outcome of infected pts depend on rapid diagnosis,appr.resuscitation and appr surgeries wr indicated.THANK YOU