Pathophysiology • Fever >38ºC is common after surgery • Usually inflammatory stimulus of surgery and resolves spontaneously • Fever = response to cytokine release • Fever-associated cytokines are released by tissue trauma and do not necessarily signal infection • Cytokines produced by monocyte, macrophages, endothelial cells • Fever-associated cytokines = IL-1, IL-6, TNF-alpha, IFN-gamma
DDX: The 5 W’s • Wind (POD#0) Atelectasis, pneumonia • Water (POD#3) UTI, anastomotic leak • Wound (POD#5) Wound infection, abscess • Walking DVT / PE • Wonder-drug
DDX: Immediate Fever • Immediate fever: onset in OR or in the immediate postoperative period • DDX: • Medication reactions: antibiotics, blood products, malignant hyperthermia. Often p/w hypotension. • Necrotizing infection: Clostridium, Group A β-hemo strep. Treatment: ABC, resuscitate, ABX: pip/tazo and clindamycin, surgical debridement
DDX: Acute Fever • Acute fever: first week after surgery • DDX: • necrotizing infection (within 48hrs) • anastomotic leak (classically POD# 3 to 5) • Pulmonary embolism • MI • Pneumonia • Aspiration • UTI • Surgical site infection (SSI) • ETOH withdrawal • Other: acute gout, pancreatitis
DDX: Subacute • Subacute fever: >1 week after surgery • DDX: • Surgical site infection • UTI • Line infection • Antibiotic-associated diarrhea • Febrile drug reactions • Thrombophlebitis • Sinusitis
Evaluation • ABCs • Resuscitate • HPI: anesthesia record, operative note, nursing report, flowchart • PE: • Complete exam • Look at wounds - take off dressings • Look at drain output • Check PIV sites, CVL, Foley, tubes
Labs/Studies • Labs to order if concerned for infection: • CBC w diff, sputum Cx, UCx, Blood Cx x2 • C. diff toxin assay • Imaging: • CXR (for pneumonia) • Lower extremity venous duplex (for DVT) • CT scan (for abscess, leak, pancreatitis, PE)
Management • Intervention needed? • Remove/replace sources of infection • Foley catheter, central lines, or peripheral IV’s • Open, debride, and drain infected wounds • If suspect pneumonia, bacteremia, UTI, sepsis – start broad spectrum antibiotics • Anticoagulation for DVT/PE • CT guided drainage of abscess
Case 1 • 58y M 5hrs after B/L total knee arthroplasty. Temp 38.7 C. Pain adequately controlled w/meds. No antibiotics. • PE: HR 90, BP 130/70, O2 sat: 99% • Mild serosanguinous drainage from knees • No Foley or CVL • WBC 7 • What is your plan?
Case 1 • What is your plan? • A. Urine culture • B. Blood, urine cultures & CXR • C. Blood, urine cultures & vancomycin • D. Observation only
Case 2 • 65y F w/ obesity, DM now 5hrs s/p open cholecystectomy for gangrenous cholecystitis c/o abdominal pain. Temp 40C, tachycardia. • VW: HR 140, BP 88/50, O2 Sat 94% • PE: AMS, wound is blistered, +crepitus, w/ dirty dishwater drainage • What is your diagnosis? • What is your plan?
Case 2 • What is your diagnosis? • Cellulitis • Diffuse peritonitis • Necrotizing fasciitis • Uncomplicated post operative fever • What is your plan? • Observe • ABC, resuscitate, IV antibiotics • ABC, resuscitate, IV antibiotics, immediate surgical debridement This patient is in septic shock
Case 3 • 61y F w rheumatoid arthritis on methotrexate undergoes left total hip replacement. Foley catheter present postoperatively. POD#3 temp 38.1C, Foley is removed. POD#4 temp 38.5 C. • She has been ambulating and using incentive spirometry • PE: O2 Sats and vitals are normal, wound is clean
Case 3 • What is the most likely diagnosis? • A. Deep venous thrombosis • B. Urinary tract infection • C. Superficial wound infection • D. Prosthesis infection • UTI evaluation: history, U/A, urine culture • Evaluate for other possibilities
Take Home Points • The 5 W’s • Think the worst and rule it out! • Necrotizing fasciitis must be identified and treated aggressively