FEVER IN THE POST OPERATIVE PERIOD

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Slide 1 : FEVER IN THE POST OPERATIVE PERIOD DR Fiaz Maqbool Fazili Senior surgeon specialist Ohud hospital medina KSA
Slide 2 : Our aim We belong to services group, all the people involved with us expect from us selfless service We have to put SERVICE BEFORE SELF despite our personnel constraints.
Slide 3 : Preface For centuries fever has been considered to represent a manifestation of disease, and in the surgical patient significant fever usually reflects infection. No other Clinical parameter is as easily or as dependently measured as is body temperature. Very few other measurements afford as much information about general status of post op pt.
Slide 4 : Thermoregulation Balance between heat production and heat loss Heat production-oxidative process Catacholamines Thyroxin Increase in substrate load in metabolic pathway I/3 of Heat producing activity takes place in muscle mass-increase in muscular activity like exercise or shivering has considerable effect on heat production.
Slide 5 : Heat loss Conduction & Convection Vasodilatation(transfer of heat from core to surface) Evaporation – sweating,most important mechanism of heat expenditure
Slide 6 : NORMAL BODY TEMP Normal body temp. 36.2-37.5C(97-99.9° F) Diurnal variation 0.5 to 1.5 °C (0.9-2.7°F.) *low in morn* –(max in evening). Hypothalamus regulates this-input from temp. sensitive nerve endings in viscera,skin,temp. sensitive receptors in Ant .Hypothalamus Temp. regulatory neurons in post hypo alter sweating, by vasoconst, , vasodilat and hormonal regulation Local spinal cord reflexes also regulate vasodil. and vasoconstriction.
Slide 7 : PATHOGENESIS OF FEVER FEVER=^Heat prod or Decrease heat expenditure Insufficient sweating or by vasoconstriction Increase Heat production - Elevation of Catacholamines or thyroxin Inappropriate shivering or abnormal muscle activity. PYROGENS; A febrile reaction is initiated by pyrogens. Causes are -Exogenous or Endogenous
Slide 8 : Classification of Fever INTERMITTENT; (Spiking) Intermittent elevation of temp with regular return to normal(infection within closed space-abscess. REMITTENT/FLUCTUATING; continuous type of fever drop in fever without returning to normal-brucellosis,blood stream infections, infected arterial grafts,phlebitis. UNREMITTING/CONTINOUS: unchanging high fever-CNS injury,pneumonias, typhoid Hydration, Muscle activity,sleep and medication also alter febrile response,.
Slide 9 : Altered Febrile Response AGE; INFANTS HAVE A HIGH TEMP ranging as high as 40.6 OLD AGED PT DIMNISHED RESPONSE MEDICATIONS- NSAID,Steroids-absence of fever TRAUMA; Fever in trauma is bad sign,trauma to hypothalamus disturbs thermoregulatory mechanism . IMMUNOSUPRESSION-altered production of endogenous leukocyte pyrogens, lack a febrile response
Slide 10 : FEVER IN POST OPERATIVE PATIENT WIND: WATER: WOUND
Slide 11 : FEVER IN POST OPERATIVE PATIENT WIND , WATER ,WOUND COMMON CAUSES ATELACTASIS VENOUS THROMBOSIS URINARY TRACT INFECTION SURGICAL WOUND INFECTION
Slide 12 : DAY 1-2 (24 – 48 HRS.)first day fever ATELACTASIS
Slide 13 : ATELACTASIS OR PNEUMONITIS Anesthesia agents cause increase production of secretions, as water evaporates, they become viscous.with diminished cough reflex & decrease ciliary activity - formation of mucus plug- obstruct small airways. When the gases distal to plug get absorbed the airways collapse. Febrile response is due to Low grade infection distal to obstructing plug+absorption of bacterial pyrogens n Temp elevation within 12 hrs of onset of plug formation.max temp is characteristically 38.9oc
Slide 14 : PNEUMONITIS contd. High risk group;cigarette smoking,chronic bronchitis, COPD 3% of all ORS, 15%abdomen, 25% upper abdomen Continued atelactasis predispose to full blown pneumonitis Prevention; stop smoking, spirometery assess pulmonary mechanics,consider intercostal blocks-thick mucus secretions need inhalations to FOB, chest physio, early mobilization.
Slide 15 : Third DAYsurgical fever48-72HrsTemp elevation to 40.6 to 41.1 Phlebitis
Slide 16 : PHLEBITIS IV catheter sepsis DVT and pul. embolism Suppurative thrombophlebitis
Slide 17 : Temp elevation to 40.6-41. 1°C Tacchycardia, Hypo tension, Oliguria, Prostration,Leukocytosis, Hard chills-52%develop septic shock, mort. rate 40% > 40yrs age and 80% in > 80yrs.age. Tenderness and erythema around catheter. Precipitating causes Causes;Hyperosmolar infusate,K conc sols, antibiotics, size of vein in which catheter.This can be decreased by adding one unit of heparin. IV septic technique Cath sepsis reduced from 23% to 4% keeping Iv catheter in place for max 12 hrs.
Slide 18 : IV catheter sepsis Lack of aseptic technique Use of hypertonic solutions Multiple infusions through same line Change of site after 72 hrs. Early signs-Red streaks
Slide 19 : Third and Fourth DAY fever Cause >>> DVT &PUL EMBOLISM
Slide 20 : DVT & PUL. EMBOLISM 3 -4 days Temp ^ calf tenderness(Hommans sign) Doppler ultrasound, has replaces contrast venograms. Treatment is PREVENTION Identify High risk group from pre-op stage. Start prophylactic heparin sub cut perioperative Mechanical means
Slide 21 : PULMONARY EMBOLISM SEQUELAE OF DVT FEVER DOES NOT APPEAR UNTIL PUL THROMBO EMBOLISATION-PAIN CHEST, DYSPNOEA, TREATMENT IS PREVENTION THERAPEUTIC DOSE OF HEPARIN NEED HDU
Slide 22 : SUPPURATIVE THROMBOPHLEBITIS PRESENCE OF SUPPURATIVE INFECTION IN VEIN IS OFTEN LETHAL-NEED LIGATION OF VEIN HIGH FEVER , REMITTENT TYPE COMMON SITES ARE; Basilic,Cephalic, Neck veins OCCASIONALLY SEEN IN PELVIC VEINS after SEPTIC ABORTION, AND PID.
Slide 23 : URINARY TRACT INFECTIONS Most common nosocomial infection (40%) 75%ps have some form of urine tract manipulation Bacteria found in urine in 1-5% of pts undergoing short term catheterization, 90% pts in whom Foley is left for 48hrs or more Post op UTI; temp 39.4-40°C, rigors/chills Management –prevention, PUT Catheter only when must, Aseptic technique , closed drainage system.Discard drainage system if accidentally disconnected and change when obstruction or contamination occurs.
Slide 24 : DAY 5-8 FEVERcause surgical wound infection
Slide 25 : SURGICAL INFECTION Wound infection‘ present as abscess-cellulites Signs of erythema, foul discharge,indurations, soakage Treatment is adequate drainage &/antibiotic coverage Factors responsible-pt related , disease related, procedure related, environment related. Lack of preventive measures.
Slide 26 :
Slide 27 : BENIGN POST OP FEVER During OR Thermo regulatory mechanism Hypothalamus becomes inhibited by Anesthetic agents –fall in body temp,thermo neutrality with atmosphere Once anesthesia effect is gone- recovery of this mechanism but intracranial core temp still decreased-thermosenstive receptors in hypothalamus sense decreased temp and attempt to raise body temp to hypothalic set point, often there is over compensation with a mild febrile episode in post op period This is diagnosis by exclusion
Slide 28 : Other non surgical Causes….. MALARIA,BRUCELLA,TYPHOID. MALIGNANT DISEASES POST CARDIOTOMY FEVER SYNDROME BLOOD TRANSFUSION PHAYNGITIS
Slide 29 : OTHER CAUSES Hyper metabolism -increased BMR in response to surgery –burn pt, returns to normal with wound healing Drug induced Fever DEHYDRATION-decreased sensitivity to sweating mechanism Malignant Hyperthermia THYROID STORM FEVER OF CNS ORIGIN
Slide 30 : DRUG INDUCED FEVER Drugs that cause fever due to effects of pharmacological activity; Antibiotics, Cytotoxic agents Drugs causing fever due altered thermoregulation atropine Catacholamines, (Decrease sweating) Increased BMR-thyroxine derivatives Drugs causing fever due to contaminants; IV solutions Drugs that cause fever indirectly; anticoagulants Drugs causing fever due to hypersensitivity-sulphas, pencillins,
Slide 31 : MANAGEMENT OF POST OP FEVER Measures/procedures to determine cause History;onset,type, medication-blood transfusion Exam;chest,iv sites, lower limbs Dvt, cva tenderness, ENT exam, assess Hydration, Lab work. Cbc, urine rout/cs,CXR, C/s-Throat, nasopharynx, wound, blood culture ( x2 )if temp >38.9 Culture; Drain or tube,or cath tips, iv caths Typhoid, Brucella-tests. Treat; underlying cause.Treat fever, maintain hydration, nutrition
Slide 32 : SUMMARY Fever is common and readily detectable manifestation of disease .In the post op pt the most common potentially serious causes are atelactasis or other pulmonary problems, phlebitis in deep veins or at iv sites, UTI, and surgical wound infection. Other benign and potentially serious causes occur less commonly but must be suspected when more common causes are not found.treatment directed towards cause. Fever controlled by salisylates and by mechanical means if control is warranted,
Slide 33 : We offer safe hands…..
Slide 34 : Thank you!!

 


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