Pneumonia. UTI. Post-Op Fever- Subacute. Differential ..

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Morning ReportPost-Operative Fever

• June 1, 2004
• Jennifer Caffey, D.O.

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HPI

• CC Fever x 2 days
• HPI 19 months old female with 2 days history of
  fever, max. 102F. Emesis x2, described
  as non-bilious, non-bloody. Appetite decreased
  but tolerating oral fluids. Good urine output.
  No sick contacts.
  Status-post Open Reduction, Internal
  Fixation 5 days prior to admission for
  developmental dysplasia of the left hip.

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Review of Systems

• No URI symptoms
• No pain in extremities
• No dyspnea
• No chest pain
• No diarrhea, no constipation
• No rashes

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Past History

• PMH developmental dysplasia of left hip
• PSH 2 prior corrective surgeries on left hip,
  1st on May 6, 2nd on May 20, 2004
• Birth term AGA female born via
  C-section secondary to hand presentation.
  Pregnancy complicated by transient episodes of
  maternal hypotension. Normal nursery stay.

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History (cont)

• Previous Hospitalizations 9 mos for febrile
  illness. Twice in May 2004 for hip surgery.
• Meds Tylenol prn fever
• Allergies NKDA
• Immunizations UTD by history
• Diet well rounded, age-appropriate

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History (cont)

• Family Hx Maternal grandmother with Type II DM
• Social Hx Lives with mom, dad, 5y/o brother and
  2m/o brother. Dad is a smoker. Cats outside.
  No daycare.
• Developmental Speaks Spanish only, multiple
  single words

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Physical Exam

• V/S T 37.3 (ax) HR 145 RR 24
  BP 103/53 Wt 15kg (gt95th)
• Gen Lying on back in SPICA cast
• HEENT normocephalic, PERRL, red reflex intact,
  nares patent, TMs clear Bilaterally, moist
  mucosa, oropharynx with mild erythema, no
  cervical lymphadenopathy
• Heart regular rhythm, no murmurs

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Physical Exam (cont)

• Lungs Limited exam secondary to cast, upper
  lobes clear to auscultation bilaterally
• Abd Limited secondary to cast, bowel sounds,
  lower abdomen soft, not tender
• Ext lower extremities in cast, lower extremity
  pulses 2 and symmetrical
• Neuro Limited exam, no focal deficits
• GU normal female genitalia, left hip wound
  dressed and without drainage.

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LABS (initial)

• CBC WBC 15.6 H/H 8.6/27.2
• G 69.5 L 19.6 M 10.4 E 0.2 B 0.2
• Platelets 459,000
• Blood Culture -- drawn
• CXR Lungs are clear except for some increased
  opacity behind the heart that may represent
  atelectasis.

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Labs during Hospital Stay

• ESR 98 (5/26), repeat 78 (5/28)
• CRP 10.2 (5/26), repeat 2.1 (5/28)
• Blood Culture negative at 73 hours

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Differential Diagnosis

• UTI
• Wound infection/abscess
• Pneumonia
• Vascular/venous catheters
• Deep vein thrombophlebitis
• Others?

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Postoperative Fever

• Fever gt 38 is common in 1st few days after major
  surgery
• Most early post-op fever caused by inflammatory
  stimulus of surgery and resolves spontaneously

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Postoperative Fever (cont)

• Pathophysiology of fever
• - Fever is manifestation of cytokine release in
  response to stressful stimuli
• - Cytokines released include interleukin-1,
  TNF-alpha, IFN gamma
• - Fever-associated cytokines released by tissue
  trauma and do not necessarily signal infection

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Postoperative Fever (cont)

• Timing of fever after surgery is important in
  establishing differential diagnosis
• - Immediate - onset in operating suite or
  within hours after surgery
• - Acute- onset within 1st week after surgery
• - Subacute - onset from 1 to 4 weeks after
  surgery
• - Delayed onset gt1 month after surgery

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Post-op Fever- Immediate

• Differential Diagnosis
• Medications or blood products,
• Immune mediated reactions to transfused blood
  products and antimicrobials, and
• malignant hyperthermia
• Fever due to trauma of surgery resolves within
  2-3 days (fever due to severe head trauma may be
  persistent and not resolve for days to weeks)

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Post-op Fever- Acute

• Differential Diagnosis
• Nosocomial infections
• Community acquired infections
• Surgical site infection
• Intravascular catheters
• Pneumonia
• UTI

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Post-Op Fever- Subacute

• Differential Diagnosis
• Surgical site infection
• Central venous catheter related infections
• Thrombophlebitis
• Antibiotic associated diarrhea
• Drug Fever
• Deep Vein Thrombophlebitis
• Pulmonary Embolism

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Post-Op Fever- Delayed

• Differential Diagnosis
• Infection
• Viral infections from blood products
• Surgical site infections

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Causes of Post-op Fever

• Infectious
• Surgical site infections
• Pneumonia
• UTI
• Catheter infection
• Sinusitis
• Meningitis
• Parotitis
• TSS

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Causes of Post-op Fever

• Non-Infectious
• Stress of surgery
• Medications
• Malignant hyperthermia
• Deep vein thrombosis
• Fat embolism
• Transfusion reactions
• Atelectasis?

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Orthopedic Procedures

• Complications
• Spontaneously resolving fever is the rule after
  major orthopedic surgery
• Differential Diagnosis
• Surgical Site Infections
• Hematoma
• Deep Vein Thrombosis/Thrombophlebitis

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Approach to Patient

• Evaluate patient systemically taking into account
  timing of onset of fever and the various possible
  causes
• Initial screen
• Wind,
• Water,
• Wound,
• What did we do ?

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Approach to Patient (cont)

• Wind consider pulmonary causes including
  pneumonia, aspiration, embolism
• Water consider UTI
• Wound consider surgical site infection
• What did we do ? consider treatment
  interventions including medications, blood
  product transfusions, and intravascular,
  urethral, nasal and abdominal catheters

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Treatment

• Remove unnecessary treatments including
  medications and catheters
• Suppress fever with tylenol
• Antibiotics per clinical judgment/culture results