all about post op fever

1. POST OPERATIVE FEVER
DR.INDUMATHI B

2. FEVER
• Fever is an elevation of body temperature that
exceeds the normal daily variation and occur in
conjunction with an increase in hypothalamic set
point.
• At 6 am – more then 98.9 deg F
• At 4 pm – more then 99.9 deg F

3. TYPES OF FEVER
• Continuous fever-fever occur all over 24 hour
with difference between max and min >1 deg
celsius.
• Eg. 1st week of typhoid fever

4. TYPES OF FEVER
• Intermittent fever -occur daily but touches to
normal limit once during 24 hour.
• According to pattern they can be:
• Quatidian – fever every 24 hour (P.
Falciparum, TB, UTI)
• Tertian – fever every 48 hour (P. Vivax)
• Quartan – fever every 72 hour (P. Malaria)

5. TYPES OF FEVER
• Remittent fever -occur all over 24 hour with
difference between max and min is more than 1
deg C and never touches to normal limit.
• Eg. 2nd week of typhoid fever
• Relapsing – period of fever followed by period
of normal tempurature.
• Eg. Pel-ebstein fever – hodgkins
• Cyclic netropenia

6. Post operative fever
• Post-operative fever is defined as a temperature >
38 .3deg C (or greater than 101.4 deg F) on 2
consecutive post-operative days or greater than 39
deg C (or greater than 102.2 deg F) on any
postoperative day.
• Most of the time post operative fever occur
within 72 hours- noninfectious.
• Fever that occur after 96 hrs after surgery -
infection

7. Pathophysiology of post op fever
Tissue damage and inflammation
Activation of macrophage,endothelial cell & RES
Release of IL-1,IL-6,TNF-alpha,IFN-gamma
Act on preoptic nucleus of hypothalamus
Release of prostaglandins
Increase in hypothalamic set point

8. POD 1 TO 3
•Atelectasis-Collapse of the lung resulting in
imbalance in gas exchange.
• Due to hypoventilation in GA or decreased
diaphragmatic movement due to surgical site
pain.
• Fever, tachypnea, tachycardia, dull on
percussion over affected area and decreased
breath sounds.

9. POD 1 TO 3
• INVESTIGAIONS:
• CXR- PA and lateral
views -opacity over
affected area -
compensatory
translucency.
• ABG & Helical CT
chest.

10. POD 1 TO 3
• TREATMENT:
• Adequate pain control
• Early ambulation
• Incentive spirometry for prophylaxis
• Chest physiotherapy
• Semi-recumbent position
• No need for antibiotics
• Non invasive +ve pressure ventilation like CPAP
or BiPAP

11. POD-3
• Unresolved atelectasis results in pneumonia.
• Pneumonia is an inflammation of the lung tissue
as a result of bacterial, viral or other infection.
• Presents with fever,
• Tachypnea
• Tachycardia
• Cyanosis in severe cases
• Decreased breath sounds
• Rhonchi
• Dullness on percussion.

12. POD-3
• INVESTIGATIO
NS:
• CXR- opacity
over affected
area
• Sputum-
Culture and
Sensitivity
• ABG, CBC, CRP

13. POD-3
• TREATMENT:
• Broadspectrum antibiotics according to culture&
sensitivity.
• No role for spirometry
• Empirically anti Pseudomonas antibiotics like
Ceftazidime, Piperacillin- tazobactum
Imipenum, meropenum Etc
• Anti MRSA antibiotics like Vancomycin&
Linazolid

14. POD 3 TO 5
• Catheter associated-UTI.
• A major predisposing factor is the presence of a
urinary catheter.
• Risk increases with increased duration of
catheterization (>2 days).
• Effective prevention-avoidance or brief duration
of catheterization (e.g.48hours for elective
surgery patients)
• Use of silver alloy–coated catheters when
instrumentation is required.

15. POD 3 TO 5
• The most common causative organisms
implicated in catheter-associated UTI are
• E. coli (27%)
• Enterococcus spp (15%)
• Candida spp (13%)
• P. aeruginosa (11%)
• Klebsiella spp (11%)

16. POD 3 TO 5
• Signs and Symptoms:
• Dysuria
• Urgency
• Pelvic or flank pain
• Fever or chills.
• Urine specimen should be evaluated by direct
microscopy, Gram stain, and quantitative
culture
• The specimen should be aspirated from the
catheter sampling port after disinfection of the
port with 70% to 90% alcohol, not collected from
the drainage bag.

17. POD 3 TO 5
• Urinalysis showing more than 10*5 (CFU)/mL in
a non catheterized patient more than 10*3
CFU/mL in a catheterized patient indicates UTI.
• Urine Leukocyte esterase & nitrites are surrogate
markers for WBCs in the urine.
• Candiduria accounts for approximately 10% of
nosocomial UTIs.

18. POD 3 TO 5
• Empirical broad-spectrum antibiotics are started
because most offending organisms exhibit
resistance to several antibiotics and then
tailored according to culture and sensitivity
results.
• Patients with candiduria are managed with IV
Flucanazole

19. POD 3-7
• Surgical Site Infection:
• Clean -affect only skin structures & other soft
tissues.
• Clean-contaminated –open a hollow viscus
under controlled circumstances
• Contaminated -introduce a large inoculum of
bacteria into a normally sterile body cavity for
infection to become established during surgery
• Dirty procedures are those performed to
control established infection

20. POD 3-7
• SSI -nature of the procedure
• Location of the incision
• Body cavity or hollow viscus is entered during
surgery.

21. Risk Factors for the
Development of Surgical Site
Infections
• Patient Factors
• Increased age,
• Obesity
• Malnutrition
• Diabetes mellitus
• Hypocholesterolemia

22. Risk Factors for the
Development of Surgical Site
Infections
• Independent risk factors include:
• Ascites
• Diabetes mellitus
• Postoperative anemia
• Recent weight loss

23. Surgical Site Infection
• Mild intraoperative hypothermia is associated
with an increased incidence of SSIs.
• Perioperative oxygen administration is
beneficial for the prevention of infection.
• Oxygen has been postulated to have a direct
antibacterial effect.
• Skin closure of a contaminated or dirty incision
increases the risk of SSIs.

24. Surgical Site Infection
• Drains placed in incisions cause more infections
• Epithelialization of the wound is prevented
• Drain becomes a conduit, holding open a portal
for invasion by pathogens colonizing the skin.
• Intraoperative topical antibiotics can minimize
the risk of SSIs.
• Signs and symptoms depend on the depth of
infection

25. Surgical Site Infection
• Clinical signs –local induration ,erythema,
edema, tenderness, warmth, pain-relate
immobility-manifested before wound drainage.
• Deep incisional SSIs-tenderness may extend
beyond the margin of erythema.

26. Surgical Site Infection
• With ongoing infection, signs of systemic
inflammatory response syndrome such as:
• Body temperature >=38 C or <36 C
• Heart rate >90 beats/min
• Respirations >20/min or PaCO2 <32 mm Hg
• White blood cell count >12.0 * 109/L or <4.0*
109/L

27. Surgical Site Infection
• Cultures are not mandatory for the management
of superficial incisional SSIs.
• Drainage and wound care alone is sufficient
without antibiotics.
• Deeper infection -exudates or drainage
specimens should be sent for analysis from the
surgically opened wound.

28. Surgical Site Infection
• Treatment of SSIs:
• Open & to examine the suspicious portion of the
incision and to decide about further surgical
treatment.
• Infection confined to the skin & superficial
underlying subcutaneous tissue- open the
incision and provide local wound care .

29. Surgical Site Infection
• Antibiotic therapy of superficial incisional SSIs
indicated -erythema extending beyond the
wound margin or systemic signs of infection.
• Deeper SSIs may require formal surgical
exploration and débridement.
• Organ or space SSIs occur within a body cavity
a are directly related to a surgical procedure.

30. Surgical Site Infection
• Vacuum-assisted wound closure:
• Optimizes blood flow
• Decreases edema
• Aspirates accumulated fluid facilitates bacterial
clearance.
• Negative pressure promotes wound contraction to
cover the defect
• And trigger intracellular signaling that increases
cellular proliferation.
• Sternal infections after cardiac surgery, abdominal
wall dehiscence, management of complex perineal
wounds, or securing skin grafts.

31. Surgical Care Improvement
Project Performance Measures
• Antibiotic Prophylaxis
• Glucose Control
• Hair Removal
• Normothermia

32. Antibiotic Prophylaxis
• Patients who have their antibiotic dose initiated
within 1 hour before surgical incision
• Patients who receive an approved antibiotic agent
for prophylaxis consistent with current
recommendations
• Patients whose prophylactic antibiotics were
discontinued within 24 hours of the surgery end
time)
• Clindamycin use is preferred for patients allergic to
β-lactam antibiotics.
• Vancomycin is allowed for prophylaxis of cardiac,
vascular, and orthopedic surgery if there is a
physician-documented reason in the medical record
or documented β-lactam allergy.

33. Glucose Control
• Blood glucose concentration must be maintained
<200 mg/dL for the first 2 days after surgery.
• Blood glucose determination closest to 6 AM on
postoperative days 1 and 2 is monitored.

34. Surgical Care Improvement
Project Performance Measures
• Hair Removal
• No hair removal should be performed
• if hair is removed- clippers or a depilatory agent
should be used immediately before surgery.
• Normothermia (Colorectal Surgery
Patients)
• Core body temperature should be between 96.8°
F and 100.4° F within the first hour after leaving
the operating room.

36. POD5-7
• Most common cause of fever on postoperative
day 6 is DVT.
• DVT is often related to venous stasis from
immobility in the perioperative period.
• The deep veins of the lower limbs and pelvis are
the most commonly affected.
• A palpable indurated, cordlike subcutaneous
venous segment -Superficial thrombophelebitis.

37. POD5-7
• Most common sign is limb swelling.
• Tenderness,pain, and erythema.
• Homan’s sign -pain in the calf upon dorsiflexion
of the ankle.

38. POD5-7
• Risk factors:
• Prior hx of DVT
• Obesity
• Immobility
• Pelvic and orthopedic procedures
• Cancer
• Hypercoagulable state
• Peripheral venous disease.

39. POD5-7

40. POD5-7
• TREATMENT:
• FH(LMWH) like fondaparinux & UFH(Heparin)
should be given for 5 days and then should be
followed by oral anticoagulation with warfarin.
• Contraindications to anticoagulation -IVC filter.

41. POST OP FEVER
• Immediate
• Fever occurs immediately after surgery or within
hours on postoperative days (POD) 0 or 1
• Malignant hyperthermia
• Bacteremia
• Gas gangrene of the wound
• Febrile non-hemolytic transfusion reaction.

42. POST OP FEVER
• Acute Fever -Fever occurs in the first week (1
to 7 POD.
• Subacute Fever- Fever occurs between
postoperative weeks 1 and 4.
• Delayed Fever -Fever after more than 4 weeks

43. POST OP FEVER
• Evaluation
• Airway, Breathing, Circulatory, Disability,
Exposure
• monitor vital signs.
• Hypotensive,-venous blood gas to measure
serum lactate.
• Tachycardic-bedside ECG -rhythm, might rule
out myocardial infarction
• Monitor blood glucose levels
• Urinalysis

44. POST OP FEVER
• Blood tests:WBC, CRP, hemoglobin level, liver
function tests, coagulation parameters,
platelets,RFT,serum electrolytes.
• Cultures -blood, urine, wound, and sputum.
• Chest x-ray ,ultrasound, CT scan .
• Venous doppler of the legs

49. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Penicillin:
• Gram-positive pathogens-streptococci,
clostridia and some of the staphylococci that do
not produce -lactamase.
• Effective against Actinomyces,
• Spreading streptococcal infections.
• All serious infections, e.g. gas gangrene, require
highdose intravenous benzylpenicillin.

50. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Flucloxacillin
• Lactamase-resistant penicillin
• Treating infections with penicillinase producing
staphylococci-resistant to benzy penicillin.
• Good penetrating property
• Used in soft tissue infections & osteomyelitis.

51. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Ampicillin and amoxicillin
• Beta lactam penicillins can be taken orally or
parenterally.
• Effective against Enterobacteriaceae,
Enterococcus faecalis and the majority of group
D streptococci,
• Clavulanic acid has no antibacterial activity itself
- inactivates beta lactamse.

52. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Piperacillin and ticarcillin:
• Ureidopenicillins with broad spectrum of
activity.
• Used in combination with beta lactamase
inhibitors(tazobactam with piperacillin &
clavulanic acid with ticarcillin)
• Used in the treatment of septicemia,hospital
acquired pneumonia & complex UTIs.
• Active against pesudomonas and proteus
species.

53. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Cephalosporins:
• cefuroxime, cefotaxime and ceftazidime are
widely used.
• Most effective in intra-abdominal skin and soft-
tissue infections.
• Active against Staphylococcus aureus &
Enterobacteriaceae.
• Combined with an aminoglycoside, such as
gentamicin, and metronidazole, if anaerobic
cover is needed.

54. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Aminoglycosides
• Gentamicin and tobramycin are effective against
Gram-negative Enterobacteriaceae.
• All aminoglycosides are inactive against anaerobes
and streptococci.
• Serum levels immediately before and 1 hour after
IM must be taken,48 hours after the start of therapy.
• Ototoxicity and nephrotoxicity may follow sustained
high toxic levels.
• Marked post-antibiotic effect
• single, large doses are effective & safer.

55. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Vancomycin and teicoplanin:
• Glycopeptide -active against Gram-positive
aerobic& anerobic .
• Effective against MRSA
• Ototoxic and Nephrotoxic, so serum levels
should be monitored.
• It is effective against C. difficile in cases of
pseudomembranous colitis.

56. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Carbapenems:
• Meropenem, ertapenem and imipenem are
members of the carbapenems.
• stable to beta lactamase.
• Have broadspectrum anaerobic as well as Gram-
positive activity
• Effective for the treatment of resistant
organisms, such as ESBLresistant UTIS or
serious mixed-spectrum abdominal infections
(peritonitis).

57. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Metronidazole:
• Widely used member of the imidazole Group
• Active against all anaerobic bacteria
• Safe and may be administered orally, rectally or
intravenously.
• Infections caused by anaerobic cocci and strains of
Bacteroides and clostridia can be treated, or
prevented.
• Metronidazole is useful for the prophylaxis and
treatment of anaerobic infections after abdominal,
colorectal and pelvic surgery.

58. ANTIBIOTICS USED IN TREATMENT
AND PROPHYLAXIS OF SURGICAL
INFECTION
• Ciprofloxacin:
• Broad spectrum activity
• Effective against Pseuomonas infection
• Widespread use has been related to the
development of resistant organisms, and their
role in treating surgical infection is limited.

59. Guess who???

60. references
1.Postoperative Fever Authors
• Tony A. Abdelmaseeh1; Tony I. Oliver2.
• Affiliations- 1 Lincoln Medical & 2 University
Of South Dakota.
• 2. Fever in the Postoperative Patient Mayur
Narayan, MD, MPH, MBAa,b,*, Sandra P.
Medinilla, MD, MPHc
• 3.Sabiston text book of surgery ,chapter 11,pg
241-280
• 4.Bailey and love chapter5 pg 42

61. •THANKYOU EVERY ONE