Download Postoperative fever MGMC

Postoperative fever
Dr. S. Parthasarathy
MD, DA, DNB, Dip Diab.MD ,DCA,
Dip software based statistics,
PhD (physiology)
What is it ??
• Fever is regulated elevation of body temperature,
in which a raised central set point---• leads to “ intentional ” increased heat generation
through some combination of shivering/muscle
contraction, peripheral vasoconstriction, and
increased metabolism in brown adipose tissue.
• Dysregulation , 41 deg. + === hyperthermia
Pyrogens in fever
Yes
Hyperthermia .
NO
IL 6 production +
Genetic
predisposition
38 degree or
38.5 degrees
a few hours
apart in two
occasions
Incidence
• 27 to 51 %
• Upto 90 % in one study if time upto one
week in a study
• Infection < 50 %
Causes
• 1.
• Infectious
↓
• Surgery related
&
• Non surgery related
2.
noninfectious
Surgery related infection
•
•
•
•
•
•
Wound infection
• Intra-abdominal abscess
• Leaking anastomosis with peritonitis
• Infected prosthetic material
• Acute cholecystitis
• Transfusion-related infection
Nonsurgery related
•
•
•
•
•
•
Pneumonia
Urinary tract infection
Infected hematoma
Systemic bacteremia
Clostridium difficile enterocolitis
Pharyngitis, sinusitis
But
infectious
Non infectious
• Medications (anesthesia or other)
• • Thrombophlebitis
Common
• • Deep vein thrombosis
•
•
•
•
•
• Adrenal insufficiency
• Malignancy
• Pulmonary embolus
• Myocardial infarction
• Thyrotoxicosis
Surgical site infection
• Superficial – easy to diagnose
• But deep -- ??
• Usually after 5 or 6 days
• But fulminant myonecrosis in the site
due to stretococcus or clostridia .
Within hours after surgery
• Periop catheters
• UTI
• Fever , bacteriuria – UTI
• Really the post op fever is due to this ??
Pneumonia
• Intubated long duration
• COPD
Settings
• Upper abdominal or thoracic surgery
• Diagnose and treat – ( other causes )
Sinusitis
• Nasotracheal intubation
• Long term ryles tube
• CT sinuses
• Cholecystitis is occasionally encountered
in the postoperative setting, and may be
either acalculous or calculous,
• patients who are older, more debilitated,
and/or on prolonged bowel rest.
• The diagnosis may be challenging to make
in patients with recent abdominal surgery
• USG abdomen
•
•
•
•
Catheter related
CVP
IA lines
Difficult to diagnose
• Strict asepsis
• Transfusion - related infections manifesting
as febrile illness may be seen after surgery,
most commonly caused by cytomegalovirus.
• Typically, these patients will develop fever
after hospital discharge, although they may
manifest with cryptic fever as inpatients
• Infected hematoma
• Days after surgery
• Bleed – clot – infect
• Clinical , USG
Infected
prosthesis
Non infectious
Why ??
• Tissue damage alone results in the
disruption of phospholipids from the cell
membrane, leading to a cascade of
prostaglandins
and
cytokines
which
eventually lead to a body temperature
elevation
25 – 50 %
day 1 fever
Noninfectious Etiologies
•
•
•
•
Antibiotics, antihistamines, barbiturates
Myelographin
Ketamine (anaes)
Drugs
Amphetamine, methamphetamine
Anti epileptic drugs
• Alcohol and benzodiazepine withdrawal
• Anticoagulants
IV
• Atropine
solutions
DVT and pulmonary embolism
major orthopedic procedures involving
the lower extremities, oncologic, and
trauma surgeries are complicated by
significant rates of VTE events, even
with appropriate prophylaxis.
No need to get infarct to get fever
Gout
• Acute exacerbation of crystal - associated
arthropathy, particularly gout, is a
reasonably common cause of fever after
surgery, but its recognition in this situation
is often delayed.
• Continue anti gout drugs
Steroid withdrawal
• chronic exposure to corticosteroid
• not continued perioperatively
• refractory hypotension, fever, abdominal
symptoms, and delirium.
• Correct with steroids
Fat embolism
• The possibility of fat embolism needs to be
entertained in the patient who has
undergone long bone fracture, correction
• Fever, respiratory distress, petechial rash,
and confusion.
Thrombophlebitis
• Look at the site of venous or arterial
cannulations
• By the side of a venflon – redness and
tenderness !!
•
•
•
•
•
Wind,
Water,
Wound,
Walking
Wonder Drugs
Wind --------------- Water
• Atelectasis
24 – 48 hours
• Pneumonia later
• UTI
• Catheter related
infections
• Anastamotic leaks
Wound
• Surgical site
• Necrotizing fascitis
• Infected prosthesis
walking
• DVT
• Embolism
Wonder drugs
What is when ??
•
•
•
•
•
•
Wind,
→
•
Water,
→
•
Wound,
→
•
Walking
→
Wonder Drugs → •
1-2 days
3-5 days
5-7 days ( 6 hours)
4-5 days
After seven days
Generally
Approach
History
•
•
•
•
•
•
•
•
•
Allergy,alcohol
arthrits
past medical history,
including history of gout,
Blood
medications and allergies,
Cough chest
alcohol and other drug use;
pain
details of the surgery itself,
Drugs, dysuria
receipt of blood products;
diarhea,dyspnea
Details –
any complaints of cough,
surgery
Breathless , chest pain, diarrhea,
ABCD
joint pain, dysuria, flank pain,
Clinical features
• Vitals
• CVS ,RS , abdomen
• Skin and wound
• Alcohol withdrawal may have also sinusitis !!
Classification of Fever
• INTERMITTENT (Spiking)
– Intermittent elevation of temp with regular return to
normal (infection within closed space-abscess)
• REMITTENT/FLUCTUATING
Continuous type of fever drop in fever without
returning to normal-brucellosis, blood stream
infections, infected arterial grafts, phlebitis.
• UNREMITTING/CONTINUOUS
Continuous high fever-CNS injury, pneumonias,
Note: Hydration, Muscle activity, sleep and medication
also alter febrile response.
Sometimes – there is something
matters
• AGE;
– INFANTS HAVE A HIGH TEMP ranging as high as 40.6
– OLD AGED Patients - DIMNISHED RESPONSE
• MEDICATIONS- NSAID, Steroids-absence of fever
• TRAUMAtrauma to hypothalamus disturbs thermoregulatory
mechanism .
• IMMUNOSUPRESSION- Altered production of
endogenous leukocyte, pyrogens, lack a febrile
response
Investigate
• TC ,DC ,urine, peripheral smear, chest
Xray,
•
•
•
•
All cultures ????
USG, CT etc..
ECG, thyroid
Serum procalcitonin – infectious ??
Do we need investigations ??
• Many a time, the fever comes down
normally within one to two weeks.
• Lab tests are useful ??
• Some bacteria results in lab but fever
comes from some other cause ??
• surgery for malignancy, bowel resection,
• number of febrile days, higher fever and
moderately increased white blood cell
count.
• Our lab investigations may be useful.
Benign postoperative fever
• Hypothalamus becomes inhibited by Anesthetic
agents –fall in body temp,
• Once anesthesia effect is gone- recovery of this
mechanism
• intracranial
core
temp
still
decreasedthermosenstive receptors in hypothalamus sense
decreased temp and attempt to raise body temp to
hypothalamic set point,
• Over compensation with a mild febrile episode in
post op period
• This is diagnosed by exclusion
Set point moves up
Postop
Preop
Aims of treatment
• To reduce the elevated hypothalamic set point
• To facilitate heat loss
• To reduce the demand for oxygen (i.e., for every
increase of 1°C over 37°C, there is a 13%
increase in oxygen consumption)
• Prevent to aggravate preexisting cardiac, CNS
pulmonary disease
• To prevent seizures in children with a history of
febrile illness
Prevention
• Clean shave and preparation
• Infection risk is reduced by using aseptic
technique during catheter insertion with maximal
barrier precautions including a mask, cap, sterile
gown, and large sterile drape,
• Less time catheter
• Orogastric tube
• Smoke stop, nutrition, preop nasal mupirocin ,
obesity ??
Treatment
•
•
•
•
•
•
Antipyretics
Antibiotics need ??
Stringent glycemic control
Respiratory support
Inotropes
Surgery
Summary
•
•
•
•
•
•
•
When to call ??
Incidence
Classification
Common causes ??
Wind water wound walk wonder drugs
What is when ??
Diagnosis , management