1. Post-operative fever Leanne Wood R6 General Surgery

2. Outline Case Review –Define post-operative fever –DDx of post-operative fever –Principals of management and treatment of post-operative fever

3. CASE ID44 yr female with epigastric pain, seen in Peach Arch Hospital HPIAbout 3 week Hx of low grade epigastric pain, increased on day of presentation, associated with nausea and decreased appetite.

4. CASE Past Md HxNone MedsNone AllergiesNone ROSNo wt loss, no fevers, no jaundice, no smoking, no ETOH

5. CASE O/EIncreased BMI, soft abdomen with no mases or organomegaly but mild tenderness in epigastrum ER physician ordered some basic blood work: WBC 5.0, Hg 114, lytes/BUN/crt all N amylase 292, other LFT/bili/INR all N

6. CASE U/SNo cholelithiasis, no bile duct dilation A complex solid and cystic mass in neck of pancreas measuring 53 X 46 X 37 mm

8. CASE CT Scan mixed solid/cystic mass at junction of the neck/body (4.3 X 3.6 X 4.4 cm) no hypervascularity, no calcification pancreatic duct dilated all the way to the tail (4.5 cm) SV/SMV confluence compressed but no thrombosis or invasion

9. CASE The patient was referred to Dr. Scudamore Initially Dr. Scudamore was going to do an ERCP, but since the lesion appeared resectable and the patient was a good operative candidate, she went directly to the OR

10. CASE She had a distal pancreatectomy The splenic artery and vein were ligated, but the spleen was not removed

12. CASE POST-OP CVL PIV Foley PICRA 2 HMV drains

13. POD #1 37 8, 120/75, 120, 16, 100% on 4L NP Does she have a fever?

14. Fever Any body temperature over 37 8 Are you concerned? What do you want to do?

15. Fever 1/3 of post-operative patients will get fevers The timing of the fever and associated symptoms are important factors to consider –Early: “atelectasis”, inflammatory response, drugs –Late: infections (superficial or deep SSI, pneumonia, UTI, vascular access lines), thrombosis A “shot gun” approach is probably not beneficial –The so-called “septic work-up”

16. A chart review of patients undergoing gynaecologic surgery Selected patients who developed post-operative fever >38.0 on two occasions within 8 hrs of each measurement Repeated analysis for temp >38. 5 Sought to determine the usefulness and cost-effectiveness of “routine septic work up”

17. Results 28.9% of patients had fever Of those, 64% had temp ≥38. 5 Of those with fever, 61% had at least one lab or radiologic test Of those tests, only 17% were positive Residents evaluated 30% of these patients at the time of their fever 55% of patients who received an investigation were not evaluated at the time of their fever Of the patients evaluated at the time of their fever, the history and physical exam did not direct investigations 59% of the time and a rote work up was performed

19. Results Overall cost for testing was $48,432 –$2,201 per serious infection Conclusion?

20. POD #1 WBC 12.8 (neu not done) No cough, no SOB, no leg pain, dressing dry, abdo soft Advanced along expected post-operative course –Sips CF, mobilize to chair, check labs

21. POD#2 37 7, 115/70, 100, 16, 100% on 4L NP WBC 13.5 Hg 77 down to 55?! No clinical signs of bleeding –Such as……? Repeat Hg (77) but also gave 1 unit PRBC

22. POD #2 38 2 Dose she have fever ? What do you want to do?

23. POD#2 Could be from the transfusion Decision to continue transfusion, give Tylenol for comfort –What if she were NPO?

24. POD #3 (very early) On call team called for temp 39 2 What do you want to do?

25. POD #3 On call team ordered blood cultures

26. POD #3 (team rounds at 0630) 39 2, 170/90, 100, 20, 99% on 3 L NP WBC 17.9 (neu 14.2) Still no cough, tolerating sips CF, hardly mobilizing Ordered urine micro and C&S, CXR Any other actions?

27. POD # 3 D/C CVL, PICRA Checked her amylase and the amylase in the drains –Amylase 26, and in drains was 177 and 180 D/C HMV Mobilize!!

28. What do you see? What do you want to do?

29. POD #4 T max 37 2, 120/80, 90, 20, 97% 2 L NP Abdo pain only when moving, taking FF with no nausea or vomiting, passing gas, no cough, mobilizing more WBC 12.3 What do you want to do?

30. POD #4 Follow up on blood and urine cultures –Both negative at 24 hrs D/C foley D/C last HMV MOBILIZE!

31. POD #5 T max 38, 140/80, 100, 18, 98% 2L NP Dose she have fever ? What do you want to do?

32. POD #5 No cough, urinating freely, wound looks healthy, had a BM, abdo soft and not distended, PIV site OK What do you want to do?

33. POD #5 WBC 13.1 (neu 8.3) other labs N Cultures still negative Encourage mobilization Try to wean oxygen

34. POD #6 T max 38 2, 150/85, 95, 98% on 2L NP Dose she have fever ? What do you want to do?

35. POD #6 WBC 15.9 (neu 10.2) Previous cultures still neg What do you want to do?

36. What do you see?

38. Case Wrap-up LLL effusion and atelectasis Evolving splenic infarct No fluid or abscess in the abdomen Improved clinically –T max intermittently 38, weaned from oxygen, mobilizing, eating WBC continued to rise to 30! WHY?

40. Post-op fever: Summary It is important to evaluate the patient with a history and physical exam and order investigations appropriately –**routine septic work up is not cost-effective** Be in tune to the unique circumstances of the patient –Dirty wound –Intra-op blood transfusions –Length of OR time –Hypoxemia –Hypothermia

41. Post-op fever: Summary Put the fever in context –Other signs of sepsis or respiratory distress (BP, HR, U/O, sats) –Timing of fever Number of days post-op Recurrent or sustained –Associated WBC –Associated symptoms and signs

42. Thank You!