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Victoria Hall Intern The page..... “Mr Jones in 3SW Bed 44 has just spiked a fever. Please review....” What do you want to know over the phone? What do you want to know over the phone? Clarify what “fever” is – what was the recorded temperature? How long have they had the temperature for? What are their other vital signs? What day post-op is the patient? What was the reason for admission/ what surgery did they have? Are they able to help you out and start taking bloods? The reply... “Not really sure how long they have had the fever for. He was admitted the other day, I think his surgery was three days ago. He doesn’t look himself. His family are worried actually....His temperature is 38.1, BP 105/60, HR 90, RR 20. I’ll see what I can do about the bloods...” And in your mind... And in your mind... How sick is this patient? Do they need urgent review (haemodynamically unstable/are they met call criteria?) After your review - does the surgical registrar need to know about this patient/do you need help? What classifies as fever? Rectal temperature > 38ºC Oral temperature > 37.8ºC Axillary temperature >37.2ºC Tympanic membrane temperature > 37.5ºC Beware of the elderly patients “the older the colder”, and immuno-suppressed What is the mechanism behind fever? Manifestation of cytokine release in response to a number of stimuli IL-1, IL-6, TNF-alpha, IFN-gamma Some evidence that IL-6 is most closely correlated with post-operative fever Fever-associated cytokines are released by tissue trauma The magnitude of the trauma : degree of the fever response Bacterial endotoxins and exotoxins translocated from the colon can stimulate cytokine release and cause postoperative fever NSAIDs and glucocorticoids suppress cytokine release and thereby reduce the magnitude of the febrile response Systemic Inflammatory Response Syndrome SIRS is the clinical syndrome that results from a dysregulated inflammatory response to a non-infectious insult, such as an autoimmune disorder, pancreatitis, vasculitis, thromboembolism, burns, or surgery. Two or more of the following be present: Temperature >38.3ºC or <36ºC Heart rate >90 beats/min Respiratory rate >20 breaths/min or PaCO2 <32 mmHg WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms What day post op is the patient? Day 1-2: unlikely to be an infection, often related to inflammatory stimulus of surgery Day 2 -7 : nosocomial infections – pneumonia (ventilator associated or aspiration), urinary tract infection, intra-vascular catheters, non-infectious causes Day 7 +: wound infection, antibiotic-associated diarrhoea (ie C.Difficile) Delayed (often discharged home): wound infection, implanted medical devices, infective endocarditis Atelectasis as a CAUSE of fever? Both occur frequently after surgery Their concurrence is probably coincidental rather than causal Studies of abdominal surgery patients have found that there was no association between fever and the presence of, or the degree of, atelectasis [73]. Fever does not always mean infection! What are the non-infectious causes of acute fever in the surgical patient? Non-infectious causes of fever... P.E. DVT Pancreatitis Myocardial infarction Acute gout Alcohol withdrawal Iatrogenic: medications (antibiotics, heparin), transfusion reaction, drug-drug interactions (ie serotonin syndrome) Approach to the febrile surgical patient Quick bedside “look” test – are they well or unwell? What are their vital signs? Is it actually a fever? Are they haemo-dynamically stable? What is their RR (measure it yourself...)? Have they had previous fevers? What is the trend? Approach to the febrile surgical patient Take a history! What do you want to know? Keep an open mind Read through their inpatient notes, look at their medication charts – are they on antibiotics? Were they previously on antibiotics? History... History of the fever, associated chills or rigors? Malaise, lethargy, decreased exercise tolerance Associated symptoms... Chest: cough, sputum, dyspnoea, haemoptysis, wheeze, pleuritic chest pain Meningism: neck stiffness, photophobia, headache, seizure Urinary: dysuria, haematuria, frequency Abdominal: pain, nausea, vomiting, diarrhoea, ileus History... Wound/IVC: tender, erythema, purulent discharge, wound breakdown Skin: rash, splinter haemorrhages Joint exam: red, swollen joint, tender, decreased ROM/mobility, pain Mental state – are they able to give you a history? Are they in a delirium? (and could this be the cause?) History... Other clues... What was the reason for admission? Are they immuno-compromised? Is the patient a diabetic? Any exotic travel recently? Have they received DVT prophylaxis whilst an inpatient? Has it been administered? What is their risk for PE? What medications are they on? Could this be a drug fever? Approach to the febrile surgical patient Thorough examination – you are looking for clues/source of the fever... Including bedside tests – ECG, urine dipstick On Examination... Use the history to guide you A,B, C Look for signs of shock: mental state, peripheries / capillary refill, hourly urine output Rash IV access sites Surgical wound(s)/biopsy site Do they have a catheter in? What colour urine is it draining? On Examination... Proper physical examination: Cardio-respiratory, abdominal, neurological, joint – what are you looking for? Tender calves? Blood transfusion? What investigations do you need to perform? Be guided by history and examination I’m going to order a “full septic screen”... And other tests? Investigations... Bloods: FBE, UEC, CRP, Coagulation profile, Blood cultures +/- LP for CSF analysis BSL ABG Urine dipstick + MCS Wound swab Catheter tip/ IVC tip CXR ECG ? CTPA (consider it!) Others for non-infectious causes Management In any acute situation - always remember ABC If they are unwell and you are worried – tell someone! Good documentation = good doctor Management ABC A: patent, no obstruction evident, speaking in full sentences B: keep SaO2 >90%, (CO2 retainers 88-92%), ABG can give answers! C: If hypotensive -> wide bore IV access, fluid bolus (watch for the patient with CCF) D: What is their GCS? Are they at risk of airway collapse? Are they delirious? Remember BSL... Management Be guided by your likely diagnosis Remove offending treatment – ie medications causing drug fever, IDC, intra-vascular access sites... Regular paracetamol will provide comfort and minimise physiologic stress of fever If you suspect infection... Be guided by Surviving Sepsis Campaign: Early resuscitation and antibiotics Isolates before antibiotics (which means 2 sets of blood cultures separated in time and place) Strong recommendation for crystalloid as initial fluid resuscitation (1L or more) – and watch for response Weak recommendation for albumin with crystalloid for severe sepsis and septic shock Usually broad spectrum antibiotics, appropriate to suspected source of infection – within one hour of diagnosis of septic shock or severe sepsis without shock Narrow spectrum once microbiology results become available Which antibiotic? Often difficult decision Use local hospital guidelines/clinician preference for recommended antibiotics Think about what you are targeting, previous antibiotic exposure, immuno-competency of the patient and how severe the infection is Management Review, review, review The patient and their results Are they improving or getting worse? Have they responded to your fluid challenge? Do you need to re-think your initial diagnosis? Handover! Any questions? References Weed HG, Baddour LM, Up To Date 2012, Postoperative fever. Viewed Oct 8 2012. Available at URL www.uptodate.com Neviere R, Up To Date 2012. Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis. Viewed Oct 8 2012. Available at URL www.uptodate.com Cadogan M, Brown FT, Celenza T, 2011, Marshall and Ruedy’s On Call – Principles and Protocols, 2nd Edition, Saunders Australia. Surviving Sepsis Campaign 2008, Surviving Sepsis Campaign Guidelines. Viewed Oct 8 2012. Available at URL: http://www.survivingsepsis.org/Pages/default.aspx