Most common cause of fever after surgery?

Post Operative FeverCauses of Fever (think of five W's: Wind, Water, Wound, Walking, Wonderdrug)

Workup: CBC with differential, CXR, 2 blood cultures, UA, Urine Cx

1) Atelectasis (POD 1-2)

a. Most common cause of post-op fever

b. Risk factors: prolonged immobilization, smoking hx, lung dz

c. Sx: low grade fever, rales on auscultation, tachycardia, tachypnea

d. Tx: bronchoscopy

2) Pneumonia (POD 1-2)

a. Risk factors:

i. Respirator use (Pseudomonas, Klebsiella)

1. Tx: aminoglycosides + penicillin

ii. Aspiration

1. Tx: NGT for decompression, oxygenation

b. Sx: cough, sputum production; Vitals: fever, ↑ RR

c. Findings: CXR infiltrate, Leukocytes on CBC

3) UTI (POD3+)

a. 5% chance per each day foley is in

b. Sx: burning sensation upon urination; no pain if Foley still in

c. Risk factors: prostate hypertrophy, Diabetes, catheters, urinary retention

d. Microorganisms: Pseudomonas, Serratia, Enterococcus, E.Coli, Proteus, Klebsiella

e. Findings: leukocyte esterase and nitrite changes on UA; growth on Urine Cx, leukocytes on CBC

f. Tx: remove foley, increase fluids, Abx

4) Wound (POD 5+)

a. Sx: >2cm erythema, swelling, warmth, pain around incision site

b. Microorganisms: Staph most common

c. GI infections: E. coli, Bacteroides, Enterococcus

d. GU infections: Pseudomonas, Proteus

e. Tx: drain and wet-to-dry dressings twice daily

f. Other complications: hematoma, seroma, dehiscence (fascial opening)

5) DVTs (POD7+)

a. Sx: leg edema, tender superficial veins, chest pain, tachycardia, tachypnea, SOB

b. Studies: Doppler, venogram, CT (look for occlusion in pulmonary arteries)

c. Tx: ambulate, SCDs, systemic heparin, consult cardio

6) Medications - drug rxn can occur anytime

7) Line infections

a. IV lines need to come out after 72hrs

b. Sx: fever, leukocytosis on CBC, bacteremia on blood Cx, (+) culture from line tip

c. Micro: S. aureus, S. epidermidis

d. Tx: removal of line and +/- IV Abx

8) Peritonitis

a. Perforation of GI tract à abdominal pain, fever, sepsis

b. Studies: KUB (check for free air)

c. Tx: NPO with NGT, Abx, IVF, operate to irrigate abdomen

d. Complications: abscess formation

i. Tx: localize with CT scan or Gallium study (xrays while injecting radioactive gallium into bloodstream), drain, Abx

Fever occurring during operation

1) Transfusion rxn

a. Sx: fever, excess bleeding, urticaria, red urine

b. Tx: stop transfusion, hydrate with NS, mannitol for osmotic diuresis

2) Intraoperative Septicemia

a. Release of abscess

b. Tx: copious irrigation

3) Malignant hyperthermia

a. Sx: fever, tachycardia, tachypnea, acidosis with hyperkalemia, shock

b. Causes: halothane, succinylcholine, MAOi + meperidine

c. Tx:

i. stop surgery/anesthesia

ii. dantrolene (muscle relaxant)

iii. cool patient

iv. hyperventilate to ¯ acidosis

v. bicarb + insulin to ¯ hyperkalemia and ¯ acidosis

vi. mannitol for diuresis

d. mortality 60%

Fever occurring few hours post-op

1) Thyroid storm

2) Addisonian crisis

a. Tx: resume steriod therapy for Addison's dz

3) EtOH withdrawal

a. Sx: low grade fever, tremors, seizures

b. Wernicke's encephalopathy: confusion, nystagmus, ataxia

c. Korsakoff's: confabulation, amnesia caused by damage to mamillary bodies

d. Tx: thiamine

4) Anastomotic leak

5) Clostridium perfringens wound infection