Post-Op Fever 2024 (PDF)

Post-Operative Fever Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Identify malignant hyperthermia, risk factors and treatment. Demonstrate knowledge of the evaluation, diagnosis and treatment of febrile patients...

Post-Operative Fever Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Identify malignant hyperthermia, risk factors and treatment. Demonstrate knowledge of the evaluation, diagnosis and treatment of febrile patients in the post-operative period. Malignant Hyperthermia: Definition A pharmacogenetic disorder which presents as hypermetabolic response to inhalation agents, muscle relaxants, or rarely, exercise and heat Typically presents within 30 minutes of exposure to triggering agent Emergency situation Can be fatal if not recognized and treated Proposed Mechanism Exposure to halogenated anesthetic agent Release of Ca+2 from skeletal muscle sarcoplasmic reticulum leads to increased muscle contraction Leads to depletion of ATP which increases O2 consumption, CO2 production and heat Membrane failure, leakage of K+, creatinine kinase, and myoglobin https://www.jcvaonline.com/article/S1053-0770(18)30221-0/fulltext MH Risk Factors Numerous triggers have been described in the literature Most common: Inhalation anesthetic agents Halothane, Desflurane, Enflurane, Ether, Isoflurane, and Sevoflurane All except nitrous oxide have been found to cause MH Muscle relaxant Succinylcholine h ttp s :/ / w w w.s h u tte r s to c k.c o m / v i d e o / c l i p - 1 0 0 6 8 9 3 6 2 8 - p o v - e y e s - p a ti e n t- m a l e - a n e s th e s i o l o g i s t- s c r u b s - p u tti n g Safer Anesthetics Propofol Ketamine Catecholamines Nondepolarizing muscle relaxants Digitalis Local anesthetics Benzodiazepines Barbiturates Opioids h ttp s :/ / i n.p i n te r e s t.c o m / p i n / 2 0 6 8 1 3 8 0 7 8 6 1 5 8 6 8 2 9 / Clinical Features Tachycardia (early) Unexplained elevation of expired carbon dioxide, despite increased minute ventilation Muscle rigidity (Masseter Muscle Rigidity) Hyperthermia Acidosis Hyperkalemia Cardiac dysrhythmias Rhabdomyolysis (late) Treatment Immediate discontinuation of possible causative agent May need to change any source connection to patient (change tubing) Increase minute ventilation to lower ETCO2 Cool the patient Treat arrhythmias as needed Labs: Blood gases Electrolytes Creatine Kinase Blood and urine for myoglobin Dantrolene 2.5 mg/kg initial dose, continue with same dose as needed pending symptoms up to maximum cumulative dose of 10 mg/kg total Post-Operative Fever Fever which occurs in the postoperative state Normal: 36.1 °- 37.2°C (97.7 ° 99.5° F) Temperature greater than 100.4° F or 38° C https://www.mountsinai.org/health-library/symptoms/fever 5 W’s of Post-Operative Fever Wind POD 1-2 Pneumonia/atelectasis Water POD 2-3 Urinary tract infection Wound POD 3-7 Infection/hematoma Walk POD 5-7 DVT/PE Wonder Drug POD > 7 https://teachmesurgery.com/perioperative/on-the-wards/post-operative-fever/ Post-Operative Fever 0-2 Days Pneumonia/atelectasis Aspiration pneumonia Atelectasis: condition in which the alveoli in the lung collapse or do not expand appropriately Pneumonia: infection which causes inflammation of one or both lungs May be viral or bacterial Symptoms: Cough, tachycardia, shortness of breath, inability to cough Preventative: Incentive spirometry Treatment (pneumonia): Amoxicillin, plus macrolide (outpatient) Azithromycin plus ceftriaxone (inpatient) https://radiopaedia.org/cases/normal-frontal-chest-x-ray?lang=us Normal vs Atelectasis Normal vs Pneumonia Post-Operative Fever 2-3 Days Urinary Tract Infection Symptoms: Diagnosis: History Physical exam Urinalysis Urine culture Dysuria Increased urinary frequency Malodor Treatment: Suprapubic pain Nitrofurantoin Fever TMP-SMX Flank pain Ciprofloxacin Hematuria *Do not need to treat asymptomatic Altered mental status urine culture* hypotension Post-Operative Fever 3-7 Days Wound Infection: Symptoms: Fever Chills Erythema Pain Drainage Dehiscence Management: Local wound care Culture Antibiotics Incision and drainage https://monib-health.com/en/post/96-postoperativeinfection Post-Operative Fever 5-7 Days Deep Venous Thrombosis/Pulmonary Embolism Blood clot which forms in the deep veins, usually the lower extremity, but can occur in the upper extremity Symptoms: Pain Erythema Edema Shortness of breath Chest pain Sudden death https://trombo.info/venous-thromboembolism/tromboinfo-deep-vein-thrombosis/?lang=en Post-Operative Fever 5-7 Days Diagnosis: DVT: Well’s Score D-Dimer Venous duplex Physical exam PE: Chest X-ray Chest Tomographic Angiography VQ scan Management: Coagulopathy studies Anticoagulants https://www.researchgate.net/figure/Wells-score-original-and-simplified_tbl1_5634873 Post-Operative Fever 7 Days Wonder Drugs Drug fever Transfusion Emergent Etiology of Ealy-Post Operative Fever Necrotizing soft tissue infections/myonecrosis Pulmonary embolism Alcohol withdrawal Adrenal insufficiency Malignant hyperthermia Sources Schneiderbanger, Daniel et al. “Management of malignant hyperthermia: diagnosis and treatment.” Therapeutics and clinical risk management vol. 10 355-62. 14 May. 2014, doi:10.2147/TCRM.S47632 Narayan M, Medinilla SP. Fever in the postoperative patient. Emerg Med Clin North Am. 2013 Nov;31(4):1045-58. doi: 10.1016/j.emc.2013.07.011. PMID: 24176478. Modified from Dr. Bennett lecture “Post Op Fever and Complications”