POST-OPERATIVE

FEVER
:FEVER
Fever is a rise of the normal core
temperature of an individual that
exceeds the normal daily variation and
occurs in connection with an increase
in the hypothalamic set point
According to studies of healthy individuals
18 to 40 years of age, the mean oral
temperature is 36.8° ± 0.4°C (98.2° ± 0.7°F)
Temperatures exceeding 38°C (100.4°F) and
persisting for more than two postoperative
days are generally considered to be
[.clinically significant
POST-OPERATIVE FEVER
Post-operative fever is a common
condition challenging doctors to
find the right diagnosis because it
can be a hallmark of serious
underlying condition
PATHOPHYSIOLOGY
Fever associated cytokines are IL-1, IL-6, TNF-
ά and IFN-gamma
IL-6 is most closely related to post-op fever
Cytokines released by tissue trauma or
infections
Degree of trauma and Genetic factors may also
influence the magnitude of cytokine release
 CAUSES OF POST-OP FEVER
SUMMARISED IN 5 W’S that are also
correlated with the specific time
:period after surgery
WIND
WATER
WALKING
WOUND
WONDER DRUGS
WOUND: POD 5-7
surgical site infection

+WONDER DRUGS: POD 7

drug fever, infection related to I/V
lines
POD 1-2WIND:
Lungs i.e. pneumonia, aspiration, pulmonary
embolism but primarily atelectasis

WATER: POD 3-5

UTI related to foley’s catheter

WALKING (or veins): POD 4-6

DVT, pulmonary embolism
Infectious and non-infectious causes
of fever in the post-operative patient
Infectious—Surgery
Wound infection •
Intra-abdominal abscess •
Leaking anastomosis with peritonitis •
Infected prosthetic material •
Transfusion-related infection •
Pheochromocytoma •
Infectious—Not Surgery Related
Pneumonia •
Urinary tract infection •
Infected hematoma •
Systemic bacteremia •
Pharyngitis •
Related—non-infectious
Atelectasis •
Medications (anesthesia or other) •
Thrombophlebitis •
Drug fever •
Malignancy •
Pulmonary embolus •
Deep vein thrombosis •
Myocardial infarction •
Thyrotoxicosis •
ASSESSMENT OF
PYREXIAL PATIENT
Fever should never be ignored.
Appropriate evaluation of early
postoperative fever includes a
careful history, a targeted physical
examination and additional studies
.if indicated
If you listen carefully to the“
patients, they will tell you the
”.diagnosis

OSLER-
HISTORY
 PHYSICAL EXAMINATION
A careful search for the infective cause
: should be made
Skin and subcutaneous tissues
Chest
Urinary tract
Abdomen
Pelvic organs
Bone
Central nervous system
INVESTIGATIONS
The work-up for post-op fever should be
judicious
No undue investigations should be done
to maximise their cost-effectiveness
Infective causes of pyrexia should be
differentiated from non-infective
causes by the history and clinical
.examinations
 Bacteriological assessment
blood culture -
sputum -
pleural or peritoneal aspirate -
urine -
skin and wound swab of discharge -
cerebrospinal fluid (by lumbar puncture) -
intravascular catheters -
aspiration of tissue fluid from spreading -
edge of cellulitis
 Hematological assessment

Complete Blood Count with ESR -

Platelet count -
Coagulation profile -
Serum biochemistry -
- Urea, electrolytes and creatinine
- Liver function tests
- Glucose
- Myocardial enzymes
- Serum amylase
 IMAGING
Chest X-ray -
Ultrasound -
CT and MRI -
Bone scan -
ECG and Echo cardiography -
MANAGEMENT OF
POST-OP FEVER
 TREATMENT OF
NON-INFECTIVE FEVER

:ANTIPYRETICS
NSAIDs
Aspirin -
Paracetamol -
Aspirin and NSAIDs effectively reduce fever
but they have adverse effects on platelets
and GIT so preferred treatment is
paracetamol
 TREATMENT OF
INFECTIVE FEVER
Resuscitation and control of systemic -
infection

Identification of the source of - -

infection

Elimination of the source-

 ANTIBIOTICS
Antibiotics should ideally be given -
according to the culture and
sensitivity tests

If not available, empirical therapy -

should be used
 FLUID RESUSCITATION
Hypovolaemia is an early feature of
.developing septic shock and bacteraemia
Vigorous fluid replacement may abort the
.progress to the 'cold' shock
Therefore, expansion of plasma volume is
required with the usage of gelatine
solutions or starch solutions in addition
.to crystalloid
INOTROPES AND VASOACTIVE AGENTS -
RESPIRATORY SUPPORT -
SURGICAL THERAPY -
Drainage of pus -
Excision of diseased organ -
Correction of lesions causing -
obstruction of hollow organs,
elimination of spaces in which
.infection may develop
Fever can appear for both infectious and non- -
TAKE HOME MESSAGE
.infectious reasons after an operation
In the first 24 hours after operation, 27% to -
.58%of patients may develop fever
Physical examination should include the -
respiratory, cardiovascular, urinary, and
gastrointestinal systems, as well as an
.examination of the skin
Thrombophlebitis can often be treated with -
.warmcompresses and anti-inflammatory agents