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Fever in the Post-Operative Patient: a Chilling Problem

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Fever in the Post-Operative Patient: a Chilling Problem Focus on CME at the University of Manitoba Fever in the Post-operative Patient: A Chilling Problem Christopher Sikora, BSc, MSc; John M. Embil, MD, FRCPC Presented at “Bug Day 2003”, Health Sciences Centre, Winnipeg (October 2003). Andy’s Pain Angela’s Recovery Andy, 72, presents to the Angela, 67, is recovering emergency department with uneventfully in hospital from a abdominal pain, nausea, and bladder suspension procedure. vomiting. A small bowel On the third post-operative day, she develops a sudden fever of obstruction is confirmed by 39.4 C with violent vigors. She laparotomy. On the second has associated sweats and post-operative day, he develops generalized malaise. A septic pain in and around the incision, workup, consisting of a full associated generalized malaise, history and physical and a fever of 38.8 C. Figure 1 demonstrates his examination, reveals discomfort in the left antecubital abdomen at the time the fever was detected. He is fossa where a large bore intravenous catheter had diagnosed with a superficial wound infection and been placed during the surgery. Upon further empiric antibiotic therapy is started. Staphylococcus inspection, it is possible to milk pus from the catheter aureus is recovered from the wound. insertion site (Figures 2a and 2b). Subsequent blood and urine cultures yielded Staphylococcus aureus. For a followup on Andy, go to page 97. For a followup on Angela, go to page 97. ever may be present in the post-operative peri- causes of fever in the post-operative period can be Fod for both infectious and non-infectious rea- classified in three categories (Table 1). sons. It is important not to overlook the non-infec- What are the common n the first 24 hours after an operation, causes? I27-58% of patients may develop fever. The classic “5W” mnemonic for remembering the causes of fever in tious causes when a fever is present, as the cause the post-operative period is Wind, Water, may be quite benign, or may be indicative of a seri- Wound, Weins/Wings, and Wonder Drugs. ous underlying process. Neoplasms or collagen These five causes are also time-dependent vascular diseases account for many underlying and are likely to occur in a relatively pre- fevers. An infectious process is present in less than dictable sequence (Table 2). half of febrile post-operative patients.1 General The Canadian Journal of CME / May 2004 93 Fever Table1 Doris’ Discomfort Infectious and non-infectious causes of fever in the post-operative patient Doris, 63, presents feeling generally unwell. A diffuse abdominal discomfort was Infectious—Surgery corroborated by her daughter, • Wound infection who noted her mother had complained of left flank pain • Intra-abdominal abscess and urinary hesitancy, urgency, and dysuria. A more extensive • Leaking anastomosis with peritonitis history revealed that • Infected prosthetic material approximately one week prior, the patient had been discharged from hospital after • Acute cholecystitis having undergone an open cholecystectomy, which • Transfusion-related infection was originally planned to be completed laparoscopically. • Pheochromocytoma The abdominal examination was unremarkable and Infectious—Not Surgery Related left flank tenderness was present on percussion. A • Pneumonia urine specimen was obtained, which was turbid, and the urine dipstick indicated many leukocytes and • Urinary tract infection nitrates. An empiric diagnosis of a urinary tract • Infected hematoma infection (UTI) was made and oral antibiotics initiated. Urine cultures returned Escherichia coli to a • Systemic bacteremia concentration of greater than 108 cfu/L. • Clostridium difficile enterocolotis For more on Doris, go to page 97. • Pharyngitis Related—non-infectious tasis, are of little concern unless associated • Atelectasis with systemic signs, such as rigors, altered mentation, or hypotension. Pneumonia may • Medications (anesthesia or other) occur several days post-surgery and is an • Thrombophlebitis important diagnosis to consider if systemic • Adrenal insufficiency signs are present; it is also important to • Drug fever question the presence of a ventilator-associ- • Malignancy ated pneumonia after prolonged intubation. • Pulmonary embolus Water • Deep vein thrombosis The patient has an increased risk of developing • Myocardial infarction cystitis the longer a urethral catheter is in place. • Thyrotoxicosis The catheter should be removed as soon as the patient is able to mobilize, or use a urinal. Wind Wound In the first 24 hours after an operation, 27% It is important not to miss something nefarious, to 58% of patients may develop fever. Most like a necrotizing fasciitis or an intestinal leak, of these cases, which are likely due to atelec- especially post-surgery. A cellulitis may be present 9494 TheThe Canadian Canadian Journal Journal of of CME CME / /April May 20042004 Fever Table2 Causes of fever according to time of onset Day One—Local causes Day Three—Systemic causes • Atelectasis • Thrombophlebitis • Wound cellulitis • Deep vein thrombosis • Urinary tract infection • Wound infection • Indwelling catheter infection • Cholecystitis • Transfusion reaction • Pancreatitis • Drug fever • Systemic bacteremia/fungemia/viremia • Thrombophlebitis • Surgical complications Day Seven and on—Surgical complications, undiagnosed disease • Leaking anastomosis Day Two—Respiratory/Catheter causes • Infected prosthetic material • Pneumonia • Deep wound infection • Urinary tract infection • Abscess • Wound cellulitis • Deep vein thrombosis or thrombophlebitis • Necrotizing fasciitis or clostridial myositis • Clostridium difficile diarrhea • Collagen/Vascular disease • Occult bacteremia • Neoplasm in the early stages of post-surgery and an abscess Weins/Wings may evolve. In late stages, prosthetic material may Veins, extremeties and all vascular access be infected and present itself as a fever. Leaking sites should be inspected for the presence of anastomosis, from gastrointestinal procedures, thrombophlebitis. Likewise, it is important may also be present later on. to consider a deep vein thrombosis in a patient who has been immobilized, or has another reason to be in a hypercoagulable state. Mr. Sikora is a senior medical student at the University of Manitoba, Winnipeg, Manitoba. Wonder drugs Dr. Embil is a consultant, infectious diseases, Always consider the patient’s previous med- University of Manitoba, medical director, Infection Provention and Control Program, Winnipeg Regional ications, as well as those received intra- Health Authority, and director, Infection Prevention operatively, as possible causes of fever. Any and Control Unit, Health Sciences Centre, Winnipeg, Manitoba. transfusion products or anti-inflammatory agents can be included in this category.2 The Canadian Journal of CME / May 2004 95 Fever Figure 1. Abdominal wall cellulites in our patient. Figure 2a. Medial to the intravenous catheter is a superficial collection of pus, which was expressed from the underlying septic vein. Evaluating a patient with post- operative fever It is important to elicit the timeline associated with the fever. Key questions to ask are: • When was the surgery? • What type of procedure was performed? • Are there pre-existing or implanted prostheses involved? • What and when was peri-operative antibiot- ic prophylaxis given? • When did symptoms begin? • Were any symptoms present prior to surgery? Figure 2b. Once this site is cleaned, a large opening of the septic underlying vein can be observed. • Were there any complications with the surgery, or a prolonged hospital stay? • Does the patient have pre-existing medical sites that were used for vascular access is also conditions that could predispose to fever? important, as an infected hematoma or throm- • Were there blood products given? bophlebitic vein may be present. Lastly, a thorough inspection of the wound A thorough review of systems, including res- site is imperative. piratory, genitourinary, gastrointestinal, neuro- • Is there a fluctuant mass palpable? logic, and cardiac is necessary. Physical exami- • Is redness or heat present surrounding the nation should include the respiratory, cardio- incision? vascular, urinary, and gastrointestinal systems, • Is there a surrounding wound cellulitis as well as a thorough examination of the skin. that may or may not be well demarcated? An examination of the peripheral or central • Is pain present? 9696 TheThe Canadian Canadian Journal Journal of of CME CME / /April May 20042004 Fever Andy’s Followup Returning to Doris Andy presented with a superficial skin and soft Doris presented with a UTI likely from the tissue infection arising directly from the incision urinary catheter inserted during surgery. E. coli site. It is possible that micro-organisms present was recovered from her urine and an ultrasound on the skin at the time the original incision was of her kidneys revealed findings compatible made were inoculated into the surgical site. This with pyelonephritis on the left side. Since she patient received several days of parenteral was clinically stable, she was provided oral antimicrobial therapy and was then discharged ciprofloxacin and had an uneventful recovery. home on oral antibiotics with a complete resolution of his infection. Table 3 Revisiting Angela Applicable laboratory tests • Urinalysis Angela presented with S. aureus bacteremia arising from the insertion of the intravenous • Complete blood count with differential and cannula required for administering the peripheral smear anesthetic. S. aureus bacteremia
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