Post op pyrexia
Download as PPTX, PDF11 likes4,091 views
1. The document discusses postoperative pyrexia (fever), its causes, evaluation, and treatment. 2. Causes of postoperative fever include infectious factors like pneumonia, UTI, and wound infections, as well as non-infectious factors like atelectasis, drug reactions, and thromboembolic events. 3. Evaluation of the patient and fever involves considering timing of onset, surgical and medical history, examination of surgical sites and body systems, and diagnostic tests tailored to suspected causes. Proper diagnosis guides management, which may include antibiotics, source control, or treating underlying conditions.
Post op pyrexia
- 1. EVALUATION OF POSTOPERATIVE PYREXIA Dr. Nabarun Biswas Registrar Surgery MMCH
- 2. What we know Immediate postoperative : Metabolic response Blood transfusion Drug reaction Thyroid storm Malignant hyperthermia Cause of post operative fever: 1st & 2nd POD: Atelactesis
- 3. 3rd, 4th & 5th POD: Chest infection Phlebitis UTI Drain tube tract infection 5th, 6th & 7th POD: Wound infection Anastomotic leakage Intra abdominal abscess After 1st week: DVT Intra abdominal abscess Cause of post operative fever:
- 4. Introduction Predisposing factors Pathophysiology Differentials Evaluation Treatment Conclusion What we are going to know
- 5. The postoperative period begins immediately after surgery The length of the post operative period is variable Complications can occur in this period, one of such is post operative pyrexia (fever)
- 6. Fever is an elevation of body temperature that exceeds the normal daily variation and occurs in conjunction with an increase in the hypothalamic set point ◦ Normal body temperature range: 36.6°C-37.5°C ◦ 37.2°C @ 6am ◦ 37.7°C @ 4pm Types of fever: ◦ Continuous (sustained) ◦ Intermittent ◦ Remittent ◦ Relapsing
- 8. Post operative pyrexia can be defined as a core temperature >38°C on two consecutive post operative days or >39°C on any one post operative day Axillary temperature < 0.5°C core temperature Some causes of post operative pyrexia are self limiting requiring only observation Causes could be infectious and noninfectious
- 9. 1. Pre-operative fever 2. Extent of surgery – major surgeries e.g. intrabdominal, intrathoracic 3. Factors that increase the risk of infection : e.g. Prolonged use of catheters, drains, prolonged ETT , immunosuppression, prolonged immobilization 4. Medical co-morbidities: obesity, chronic lung diseases, diabetes mellitus
- 10. Normal body temperature is primarily regulated by Hypothalamus. Infectious agents, microbial products (exotoxins and endotoxins), damaged tissue, hypoxia and compliment components stimulate Macrophages, Endothelial cell and the Immune system to release Pyrogenic Cytokines (TNF, IL-1, IL-6, IFN). These pyrogenic cytokines elevates hypothalamic set point of temperature and body temperature raises
- 14. To differentiate post op pyrexia we should consider the following: 1. The timing/ onset of the fever 2. The Surgical 7Ws menomic Wind, Water, Wound, Walk, Wonder drug, Withdrawal Wonky gland
- 15. Timing Immediate post-op pyrexia (<48 hourspost- op) Acute post-op pyrexia (48 hours – 7days post op) Subacute post-op pyrexia (7 days – 28days post op) Delayed post-op pyrexia (after 28 dayspost op)
- 16. Surgery: Inflammatory response to tissue injury release of pyrogenic cytokinesfever. This fever is usually self-limiting resolving in approximately 2 to 3 days. Pre-existing medical conditions: Pre-op fever, Surgical stress may also lead to the exacerbation of certain medical conditions, for example, thyroid storm
- 17. Drug induced: ◦ Idiosyncratic reactions: classic examples include the Malignant Hyperthermia from Inhaled Anaesthetics- Halothane,Succinyl Choline ◦ Alterations in Thermoregulation: Antcholinergics (↓sweating → ↓heatloss) ◦ Administration related: Phlebitis, Thrombophlebitis ◦ Direct pharmacologic action of the drug (drug fever): e.g. heparin, hydralazine, phenytoin
- 18. Blood transfusion reactions: Immune-mediated Complications from surgery: Haematoma, Seroma, Acute inflammatory reaction to sutures and prosthesis used during surgery Cardiovascular causes: Post-op MI, CVA, fat embolism Malaria: In Endemic regions, can occur anytime Withdrawal from alcohol: May presentas Delirium Tremens
- 19. Infectious causes of postop fever becomemore likely when postop fever is discovered after 48 hours, specially if ASA –above II, temp > 38.6 0c, WBC > 10,000/l, BUN > 15 mg/dl 3 or more present bacterial infection is 100% UTI: urethral catheterization, and genitourinary surgeries. Pneumonia: ETT, prolonged ETT, patients with increased risk of aspiration (use of NG tube, vomiting, depressed gag reflex), atelectasis Superficial thrombophlebitis: patients on intravenous cannula.
- 20. Surgical site infections: usually superficial - wound cellulitis. There are, however, 2 organisms that can cause fulminant SSI; can occur within 48 hours postop ◦ Group A streptococcal and ◦ Clostridial infections Anastomotic leak Deep venous thrombosis and PE Non-infectious causes of immediate postop pyrexia may also cause fever in this period
- 21. Deep vein thrombosis and/or pulmonary embolus from prolonged immobility Deep infections (Pelvic or abdominal abscess) Pseudomembranous colitis Infectious causes mentioned above (UTI, pneumonia, SSI)
- 22. Osteomyelitis Viral infections related to blood products— CMV, hepatitis, HIV Parasitic infections—toxoplasmosis
- 23. Wind : Atelectasis (˂48hrs) Water : UTI (48- 72hrs) Walk : DVT/PE (3-5days) Wound : Surgical site infection (5- 10days) Wonder drug : Antibiotics, heparin, inhalational anaesthetic drugs, anticonvulsants (Any TIME) Withdrawal : Alcohol (delirium tremens begin 72hrs after last drink) Wonky gland: Thyrotoxicosis (thyroid storm) Adrenal insufficiency
- 24. History Consider if patient had fever pre-operatively Respiratory: e.g.? Intubation? COPD, cough, sputum, haemoptysis, chest pain, Difficulty breathing Cardiac: e.g. chest pain, palpitation, dizziness Urinary: e.g. ?urethral catheterisation? How long? dysuria, frequency, urgency, haematuria GIT: e.g. Nausea, vomiting, diarrhoea, abdominal pain, bleeding PR Related to surgery: Surgical site pain MSS: calf pain, pain at IV catheter site
- 25. Immunocompromised? or malnourished? Co-morbidities: malignancy, hyperthyroidism, alcohol addiction Checklist: ◦ Onset, pattern, T-max of fever ◦ Anaesthetic Record for Medication ◦ Blood products administered during the perioperative period? ◦ Input/output chart and types of stools
- 26. What is the Temperature? Surgical Site – inspect and Take off any dressings, discharge, rawness? Apposition? hyperaemia undue tenderness, abnormal swelling, fluctuance Drains, urethral catheter (cloudy, bloody) Lines – e.g. IVC, CV line Chest – Tachypnoea, consolidation, crepitation Heart – murmurs, tachycardia
- 27. Abdomen – tenderness? Movement with respiration? Calf – Unilateral calf tenderness, peripheral oedema Skin - rash, jaundice, petechiae, erythema, hematoma, pressure sore Rash – toxic shock syndrome Petechiae – fat embolism
- 28. Depends on hhistory and examination finding: –Urinalysis, Urine MSU m/c/s, –Wound swab/ biopsy m/c/s –MP –Sputum m/c/s –Blood Culture –Aspirate m/c/s – FBC, S.Cr, LFT –CXR, abdominal USS, ECG, CT angiogram –Doppler USS –Others – specific to clinical suspicion
- 29. Management of postop pyrexia depends on the probable cause In general, early postop fever requires no intervention if there are no inciting factors Nursing care: exposure, tepid sponging, temperature monitoring and charting Antipyretics, Rehydration, Antiemetic
- 30. Atelectasis: Incentive Spirometry, Chest Physiotherapy, semi-recumbent position Infective causes: Treat with empirical antibiotics while awaiting c/s Remove/replace lines promptly if in tissue (IV cannula, CV line – send tip for culture) Timely removal of urethral catheter, drains Drainage of abscess, seroma, haematoma Debridement
- 31. Transfusion/Drug related - STOP transfusion, further transfusion with washed cells if immunologically mediated Thromboembolic – Treat with anticoagulation Malignant hyperthermia: IV Dantrolene Na, Supportive Care Note: increase in caloric and fluid requirement following prolonged high grade fever due increase in metabolism and insensible fluid loss
- 32. Postoperative pyrexia is a common postoperative surgical complication Fever may be infectious or non-infectious Knowledge of differential diagnosis, and systematic approach, helps in proper diagnosis and proper management When indicated antibiotics should be judiciously used depending on the possible infectious cause
- 33. Referrences: 1. Bailey’s & Love, 27th edition 2. CSD, 14th edition 3. RCS manual, 4th edi 4. Sabiston, 19th edi 5. Some online journals