1. Postoperative Fever

2. Pathophysiology Fever >38ºC is common after surgery
Usually inflammatory stimulus of surgery and resolves spontaneously
Fever = response to cytokine release
Fever-associated cytokines are released by tissue trauma and do not necessarily signal infection
Cytokines produced by monocyte, macrophages, endothelial cells
Fever-associated cytokines = IL-1, IL-6, TNF-alpha, IFN-gamma

3. DDX: The 5 W’s Wind (POD#0) Atelectasis, pneumonia
Water (POD#3) UTI, anastomotic leak
Wound (POD#5) Wound infection, abscess
Walking DVT / PE
Wonder-drug

4. DDX: Immediate Fever
Immediate fever: onset in OR or in the immediate postoperative period
DDX:
Medication reactions: antibiotics, blood products, malignant hyperthermia. Often p/w hypotension.
Necrotizing infection: Clostridium, Group A β-hemo strep. Treatment: ABC, resuscitate, ABX: pip/tazo and clindamycin, surgical debridement

5. DDX: Acute Fever Acute fever: first week after surgery DDX:
necrotizing infection (within 48hrs)
anastomotic leak (classically POD# 3 to 5)
Pulmonary embolism MI
Pneumonia
Aspiration
UTI
Surgical site infection (SSI)
ETOH withdrawal
Other: acute gout, pancreatitis

6. DDX: Subacute Subacute fever: >1 week after surgery DDX:
Surgical site infection
UTI
Line infection
Antibiotic-associated diarrhea
Febrile drug reactions
Thrombophlebitis
Sinusitis

7. Evaluation ABCs Resuscitate
HPI: anesthesia record, operative note, nursing report, flowchart
PE:
Complete exam
Look at wounds - take off dressings
Look at drain output
Check PIV sites, CVL, Foley, tubes

8. Labs/Studies Labs to order if concerned for infection:
CBC w diff, sputum Cx, UCx, Blood Cx x2
C. diff toxin assay
Imaging:
CXR (for pneumonia)
Lower extremity venous duplex (for DVT)
CT scan (for abscess, leak, pancreatitis, PE)

9. Management Intervention needed? Remove/replace sources of infection
Foley catheter, central lines, or peripheral IV’s
Open, debride, and drain infected wounds
If suspect pneumonia, bacteremia, UTI, sepsis – start broad spectrum antibiotics
Anticoagulation for DVT/PE
CT guided drainage of abscess

10. Case 1
58y M 5hrs after B/L total knee arthroplasty. Temp 38.7 C. Pain adequately controlled w/meds. No antibiotics.
PE: HR 90, BP 130/70, O2 sat: 99%
Mild serosanguinous drainage from knees
No Foley or CVL
WBC 7
What is your plan?

11. Case 1 What is your plan? A. Urine culture
B. Blood, urine cultures & CXR
C. Blood, urine cultures & vancomycin
D. Observation only

12. Case 2
65y F w/ obesity, DM now 5hrs s/p open cholecystectomy for gangrenous cholecystitis c/o abdominal pain. Temp 40C, tachycardia.
VW: HR 140, BP 88/50, O2 Sat 94%
PE: AMS, wound is blistered, +crepitus, w/ dirty dishwater drainage
What is your diagnosis?
What is your plan?

13. This patient is in septic shock
Case 2
What is your diagnosis?
Cellulitis
Diffuse peritonitis
Necrotizing fasciitis
Uncomplicated post operative fever
What is your plan?
Observe
ABC, resuscitate, IV antibiotics
ABC, resuscitate, IV antibiotics, immediate surgical debridement
This patient is in septic shock

14. Case 3
61y F w rheumatoid arthritis on methotrexate undergoes left total hip replacement. Foley catheter present postoperatively. POD#3 temp 38.1C, Foley is removed. POD#4 temp 38.5 C.
She has been ambulating and using incentive spirometry
PE: O2 Sats and vitals are normal, wound is clean

15. Case 3 What is the most likely diagnosis? A. Deep venous thrombosis
B. Urinary tract infection
C. Superficial wound infection
D. Prosthesis infection
UTI evaluation: history, U/A, urine culture
Evaluate for other possibilities

16. Take Home Points The 5 W’s Think the worst and rule it out!
Necrotizing fasciitis must be identified and treated aggressively