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Indian J Crit Care Med Oct-Dec 2006 Vol 10 Issue 4
Teaching Aids
Postoperative fever
A. Rudra, S. Pal, A. Acharjee
Abstract
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Fever
significant.
e clinically
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Fever is a rise of the normal core temperature of
an
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n of body temperature
individual that exceeds the normal daily variation
la and MMeasurement
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a by Temperature
taken orally is about 0.5C higher than
occurs in connection with an increase in the hypothalamic
v
e
that taken in the axilla or is about 0.5C below than that
set point.
a
si ted w.mtaken rectally. Rectal temperature is considered core.The
According to studies of healthy individuals
18 to 40 lower oral readings are probably attributable to mouth
s
F
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o
years of age, the mean oral temperature
is 36.8 0.4C breathing, which is a particularly important factor in
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h higher( levels patients with respiratory infections and rapid breathing.
(98.2 0.7F) with low levels
Pat 6 amteand
between 4 to 6 pm. The imaximum
s si oral temperature is Lower oesophageal temperature closely reflects core
h
37.2C (98.9F) at 6am
and 37.7C (99.9F) at 4 pm; temperature.
T
these values define the 99a percentile for healthy
Postoperative fever is one of the most common problems seen in the postoperative ward. Most cases of
fever immediately following surgery are self-limiting. The appearance of postoperative fever is not limited to
specific types of surgery. Fever can occur immediately after surgery and seen to be related directly to the
operation or may occur sometime after the surgery as a result of an infection at the surgical site or infections
that involve organs distant from the surgery. Therefore, during evaluating postoperative fever, it is important
to recognize when a wait - and - see approach is appropriate, when further work-up is needed and when
immediate action is indicated.
[1]
[2]
th
Incidence
The incidence of postoperative fever is remarkably high.
However, published incidence rates range widely (from
14% to 91%)[3] depending on how fever was defined and
the patient population of the study. Though fever is
common, infection is found as the cause in less than
one-half of febrile patients. Studies have determined that
the incidence of postoperative fever in patients
undergoing various surgical procedures is not a specific
marker of infection in those settings [Table 1].
The overall sense from Table 1 is that, postoperative
fever is more likely to be due to the inflammatory
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IJCCM October-December 2003 Vol 7 Issue 4
Indian J Crit Care Med Oct-Dec 2006 Vol 10 Issue 4
Orthopedic surgery[6]
Tonsillectomy[7]
Cause of fever
Without infection
With infection
Without infection (open)
Without infection
(lap. chole.)
With infection
Without infection
With infection
Without infection
With infection
With infection
With focus of infection
(pulmonary, wound, urinary)
Total %
180
55
20
0
100
54
0
43
36
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response to the trauma of surgery and not a response
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to the infection. The greater surgical trauma, (e.g., open
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cholecystectomy versus laparoscopic cholecystectomy)
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the more likely is postoperative fever to occur without
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the occurrence of infection. The general consensus of
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workers in this field is that postoperative infection as a
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cause of fever after surgery is diagnosed best by specific
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symptoms and signs attributable to the infection.
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Although the trauma of surgery and infections are
lethe ed ow
b
two most common causes of fever, there are other
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common but important causes, including medications,
a band
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blood transfusion, deep venous thrombosis
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pulmonary embolism, myocardial a
infarction
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pancreatitis. Medications are a frequent cause
t of fever.
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Probably the most common medications
causing
fever
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are antibiotics, which can cause
great confusion.
P te of fever( in the
uncommon but impor tant cause
s withdrawal.
ialcohol
Trauma, including the trauma associated with surgery,
postoperative period is
Patients who
si
h
present with a fever
Tand delirium
a postoperatively must elicits the production of pyrogenic cytokines in the
Major abdominal surgery[8]
Pathophysiology
Fever may be a transient and trivial sign, which resolves
Normal thermoregulation
The control of body temperature depends upon the
following components:
1. Temperature receptors
A. Peripheral (Ad and C fibers)
B. Central (hypothalamus)
C. Other (great veins, spinal cord, abdominal
viscera)
2. Integration and control
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Indian J Crit Care Med Oct-Dec 2006 Vol 10 Issue 4
Infection
Exogenous pyrogens
e.g. bacterial endotoxins, exotoxins
Trauma
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Setting of body temperature and detection of core
lo tio
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temperature in the preoptic nucleus is done by
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hypothalamus. Moreover, posterior hypothalamus
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compares the core and peripheral temperatures with the
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set temperature. Furthermore, it induces appropriate
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actions to restore the body temperature to the set
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r
temperature. When the body temperature is higher than
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the set temperature then, the mechanism of heat loss f
will be controlled by the anterior hypothalamus. However,
le ed ow
b
the posterior hypothalamus controls the mechanisms for
and local defense mechanisms are
nsystems
la MalsoImmune
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heat gain.
affected
in addition to these systemic effects due to
d and surgery.
a by anaesthesia
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Elevation of the hypothalamic set
s
i ste w Evaluating postoperative infection
cytokines
During fever, levels of prostaglandin
F Eo (PGE ) ware Infection is more likely to be present in a patient with
D
w a fever that develops after the first two days following
elevated in hypothalamic tissue
and the
h third cerebral
(
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ventricle. The concentrations of PGEe are highest near surgery.
s sitorgans (organum Most common infections occurring after surgery:
the circumventricular ivascular
h a networks of enlarged 1. Wound infections
vasculosum of laminaTterminalis)
capillaries surrounding the hypothalamic regulatory 2. Urinary tract infections
Fever
[2]
[14]
3.
4.
5.
6.
7.
Postoperative pneumonias
Intravenous catheter-related infections
Intra-abdominal infection
Sinusitis
Prosthesis infection
Wound infections
The surgical incision interrupts the integrity of the
defense mechanism of skin. Surgical wound infection
depends on:
a) The type of surgery performed (e.g. cholecystectomy
versus colon resection)
b) The length of operative procedure
c) Whether appropriate prophylactic antibiotics are given
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IJCCM October-December 2003 Vol 7 Issue 4
Indian J Crit Care Med Oct-Dec 2006 Vol 10 Issue 4
m
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e5-7: Wound
POD
: Most
. wound infections occur during
P
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)
r
this
antibiotics are important to
f period.w Preoperative
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prevento
or reduce
the
risk
of
infection in head and neck
o
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c
fo surgery
crosses
. mucosal linings.
e edk that
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7+: Wonder drugs: Drugs can cause fevers.(Note
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li a M thatPOD
kobstetrics and gynaecology, this W is womb and
in
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v b iteprecedes Wonder drugs).
a
Intravenous catheter- related infections
d(usually.m Noninfectious causes must be considered with
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iscatheters
Can be caused either by peripheral
t w
s
leading to thrombophlebitis or F
cellulitis)
or
by central
w infectious causes in the postoperative patient because
oinfection).
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catheters (usually causing bloodstream
fever resulting from infection and trauma (i.e., surgery)
(
P
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Intra-abdominal infection
are produced through the release of similar cytokines.
t
s abdominal
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Especially seen following
or
pelvic
surgery.
However, fever in patients without evidence of infection
s
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Sinusitis
occurred closer to the surgical procedure and lasted for
T a
Typically observed in patients who undergo nasogastric
intubation for long periods.
Prosthesis infection
It may manifest within a few days of surgery, especially
if it is caused by Staphylococcus aureus.
Clinical correlation
The timing of fever relative to the postoperative day
(POD) will indicate the most likely cause. The five Ws of
postoperative fever Wind, Water, Walking, Wound and
Wonder drugs- as a useful memory tool could help a
physician when he is following patients after surgery.[15,16]
POD 1-2: Wind: Atelectasis (without air) often cause
Preoperative course
Details of the period before hospitalization can be
critical. For example, a patient with a hip fracture may
have fallen because of an occult urinary tract infection,
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Indian J Crit Care Med Oct-Dec 2006 Vol 10 Issue 4
Investigation
The tempo and complexity of the workup will depend
on the pace of the illness, diagnostic considerations and
the immune status of the host. Infective causes of pyrexia
should be differentiated from non-infective causes by the
history and clinical examinations. However, presence of
a noninfective cause does not necessarily exclude an
infective cause, e.g. patients with alcohol withdrawal may
also have pneumonia. Identification of a causative
organism and its antibiotic sensitivities should always
be attempted. It is important to sample if possible before
starting antibiotics to prevent interference with the culture.
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Bacteriological
assessment
o bl sputum, pleural or peritoneal
Includesd
blood culture,
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aspirate,
urine,P
skin and. wound swab of discharge or
)
re aspiration,
needle
stool, cerebrospinal fluid (by lumbar
f
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m catheters, aspiration of tissue
r ointravascular
puncture),
o
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n spreading
c edge of cellulitis, should be cultured
f fluid from
.
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le onedremoval.ow
b
n tests
la MHematological
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a by Inedthe presence of infection, polymorphonuclear
v
a d .mleucocyte count is usually raised. However, in severe
Physical examination
s
i sbetedone onw infections or in the immunosuppressed or malnourished
A meticulous physical examination should
a regular basis. All the vital signs
F are orelevant. The
w patient, the leucocyte count may be normal or reduced.
D
w
temperature may be taken orally
or rectally,
but
the
h ( site
P
used should be consistent.
Platelet count is usually elevated as part of the normal
te should be made: response
s scause
i
i
A careful search for the infective
to stress. However, it may be markedly reduced
h
Skin and subcutaneous
T atissues for abscess, if disseminated intravascular coagulation has developed.
necrotising fascitis and gas gangrene
History
268
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Serum biochemistry
1. Urea, electrolytes and creatinine to detect renal failure
as a common complication of severe sepsis
2. Liver function tests may be severely deranged in
severe sepsis
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IJCCM October-December 2003 Vol 7 Issue 4
Indian J Crit Care Med Oct-Dec 2006 Vol 10 Issue 4
Imaging
1. Chest X-ray- indicated for identification of areas of
occult infections, e.g. infected arterial or cardiac
prosthesis
2. Ultrasound-iIndicated for identification of venous
thrombosis
3. CT and MRI scanning required for:
a) identification of intra-abdominal and pleural
abscess;
b) assessment of infected joints;
c) assessment of kidneys.
4. Bone scan-defining intrathoracic infection and
respiratory complications of systemic infection.
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Antipyretics
o bl
Aspirindand paracetamol
interfere with the production
u
e
of prostaglandins
via
the
inhibition
of cyclo-oxygenase.
.
P
e
)
r
Prostaglandin
f w is themcentral messenger in the production
r
of pyrexia,
o whichcohelp to lower the hypothalamic set point.
n
fo However,
are indicated if the patients
.
k wantipyretics
e etemperature
d
ECG and Echo cardiography
approaches more than 39C. Reducing fever
l
o also reduces systemic symptoms of
b
For the assessments of myocardial ischaemia,
with antipyretics
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k myalgias and arthralgias.
mechanical anomalies of cardiac functioni and the headache,
d
a
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presence of intracardiac thrombosis.
av d b .meOral aspirin and nonsteroidal antiinflammatory drugs
s te w (NSAIDS) effectively reduce fever but can adversely
Outcome of diagnostic efforts i
s recovers
F
In most cases of fever, either
the patient
w affect platelets and gastrointestinal tract. Therefore,
o
w
spontaneously or the history, D
physicalh
examination
and paracetamol is preferred to all of these agents as an
(
P
initial screening laboratory studieste
lead to a diagnosis. antipyretic. In children, paracetamol must be used
s toi three
When fever continues ifor two s
weeks, during because aspirin increases the risk of Reyes syndrome.
h
which time, repeat physical
and laboratory If the patient cannot take oral antipyretics, parenteral
T examinations
a
[2]
[20]
Treatment
Treatment of the noninfective cause of pyrexia
The routine use of antipyretics given automatically as
Antibiotics
The appropriate antibiotic for the sensitives of the
cultured organisms should be used. However, in the
absence of bacteriological information therapy should
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References
a
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do ubl
e P ).
Ionotropes and vasoactive agents
e
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Systemic infections may have a myocardial depressant
f w m
r
effect. Thus, ionotropic support may be required with
o kno .co
adrenaline, dobutamine or dopexamine. Dopamine may f
be indicated to produce renal vasodilatation in casesle
of
d ow
e
b
diminished renal function.
la M dkn
i
a by e
Respiratory support
v
a d gas .m
Seriously ill, infected patients have deranged
s
i ste w
exchange and require oxygen therapy.
F o w
D
Surgical therapy
h (w
P
Elimination of a source of infectione
of the main
t is oneinfections.
s of ssurgical
i
i
principles of the management
h a
Drainage of pus T
Excision of diseased organ
Fluid resuscitation[21]
Hypovolaemia is an early feature of developing septic
shock and SIRS 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.
1.
Mackowiak PA. Fever, In: Mandell GL, Bennett JE, Polin R, editors.
2.
3.
4.
5.
6.
7.
Anand VT, Phillips JJ, Allen D, Joynson DH, Fielder HM. A study
Summary
Postoperative fever should alert the caregiver to the
possibility of an infection complicating the recovery of
the patient, but the presence of fever is not a reliable
indicator of the presence of infection and the absence of
fever does not guarantee that the postoperative patient
is infection-free. The outcome for a patient with
postoperative fever is dependent on the cause.Therefore,
postoperative fever should be evaluated with a focused
approach rather than in shotgun fashion. Noninfective
270
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9.
10. Lin E, Calvan SE, Lowry SF. Inflammatory cytokines and cell
response in surgery. Surgery 2000;127:117-26.
11. Andres BM, Taub DD, Gurkan I, Wenz JF. Postoperative fever
after total knee arthroplasty: The role of cytokines. Clin Orthop
Relat Res 2003;415:221-31.
12. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA,
et al. Definitions for sepsis and organ failure and guidelines for
the use of innovative therapies in sepsis. The ACCP/SCCM
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IJCCM October-December 2003 Vol 7 Issue 4
Indian J Crit Care Med Oct-Dec 2006 Vol 10 Issue 4
Consensus Conference Committee. American College of Chest
1992;101:1644-55.
Anesthesiology 2006;105:A393.
m
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f
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fo kno .co
le ed ow
b
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a by e
v
a
si ted w.m
s w
F
o
PD te h (w
is si
h
T a
15. Staffel JG, Denny JC, Eibling DE, Johnson JT, Kenna MA, Piman
16. Barie PS, Hydo LJ, Eachempati SR. Causes and consequences
17. Wipf JE, Lipsky BA, Hirschmann JV, Boyko EJ, Takasugi J, et al .
Diagnosing pneumonia by physical examination: Relevant or
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