13 - Post-op Fever Flashcards
Malignant hyperthermia
A life threatening elevation in body temperature
Malignant hyperthermia etiology
o Inhalation of general anesthetics (Halothane)
o Combination of muscle relaxants (succinylcholine)
Malignant hyperthermia incidence
o 1/12,000 pediatric anesthetics
o 1/40,000 adult anesthetics
Malignant hyperthermia theory
o Sarcoplasmic reticulum contains approx. 3000 times the amount of calcium normally found in the sarcoplasm
o Normal muscle contraction and relaxation involves the release and resequester of Ca++
o In malignant hyperthermia, the resequester of calcium does not occur
Malignant hyperthermia signs and symptoms
o Arrythmias o Masseter muscle spasm o Fever with increased body temp. o Tachypnea and tachycardia o Profuse hyperhidrosis o Metabolic and respiratory acidosis o Hyperkalemia
Malignant hyperthermia labs
o Abnormal ECG
o Elevated CPK
Malignant hyperthermia treatment
o Stop administration of anesthesia o Change tubing (due to residual medication) o Hyperventilate with 100% o2 o Correction of acidosis o Cool the patient (ice baths)
Malignant hyperthermia medication
Dantrolene – don’t need to know doses
o Rapid IV push until symptoms subside, also use post op
Malignant hyperthermia pre-op prophylaxis
o Dantrolene (before, during, after) o Dantrium (pre-op)
Malignant hyperthermia safe drugs
o Propofol, opioids, benzodiazepine, barbiturates, ketamine, local anesthetics, pancuronium/vecuronium, nitrous oxide
Post op temperature
- Normal = 36.5 - 37.4 c (97.7-99.5)
- Abnormal = Body temp >100.4 during post-op period is significant
Intra-op temperature
- Heat pyrexia – the patient is just cold, so the body is trying to warm up
- Malignant hyperthermia
Fever immediately post-op
- Heat pyrexia: occurs during surgery and up to 1 hour post-op
- Caused by trauma of the procedure resulting in inflammation (release of pyrogenic cytokines: IL-6,TNF, Interferon-Ɣ) and ↑ permeability
- Act on the anterior hypothalamus and cause a release of prostaglandins
5 W’s OF POST-OP FEVER***
KNOW THIS ****
Day 1-2 = Wind (atelectasis) Day 2-3 = Water (UTI) Day 3-7 = Wound (infection) Day 5-7 = Walking (DVT) Day >7 = Wonder (drugs)
12-48 hrs post-op
Atelectasis / pneumonia
o Visible collapse on x-ray
Aspiration pneumonia
o Fluid accumulation on x-ray
Spirometry
o Helps to expand the lungs to avoid the complication of pneumonia
o If you don’t have spirometry, tell the patient to cough every hour
2-3 days post-op
- Urinary tract infection *** - This is the “big one” we will see, but starting to get into wound infection time
- Constipation
- Benign post-op fever
- Hematoma (you will see fluctuance under incision site – hematoma or seroma is a risk of infection)
3-7 days post-op
Wound infection
o 5 constitutional signs of infection/inflammation (unless immune-suppressed)
o Look for the wound opening back up when it shouldn’t be
o Can’t always distinguish between infection and just edema from the surgery
5-7 days post-op
- Thrombo phlebitis
- Pulmonary embolism due to DVT
o Risk for DVT - Immobilization, Virchow’s triad = hemostasis, endothelial damage, hypercoagulability
o So much edema is present in limb, weeping of skin, breakdown of skin, blisters - Benign post-op fever
7 days post-op
Drug fever
Anytime fever
- Drug fever
- Catheter fever
- Reaction to blood transfusion
Emergent cause of early post-operative fever
- Necrotizing soft tissue infections/myonecrosis
- Pulmonary embolism
- Alcohol withdrawal
- Adrenal insufficiency
- Malignant hyperthermia
Post-operative edema
- Excessive amounts of fluid in the intercellular spaces (subcutaneous)
- Variable from one patient to another
Two types:
o 1st Type = short duration (15-30min)
- Caused by factors that increase permeability (serotonin, kinins, prostaglandins)
o 2nd Type = long duration (1-2 days)
- From leakage caused by direct injury. (endothelial destruction)
Treatment for post-op edema
- Ice, elevation, ROM exercises, compression therapy, NSAIDs, short acting corticosteroids
Hematoma vs infection – Hematoma
Hematoma
o Collection or extravasation of blood
o May lead to infection, long term swelling, and disability
Management
- Extravasation, aspiration, drains, steroid Infiltration, accelerated degradation. wound re-entry, prophylactic antibiosis
Hematoma vs infection – Infection
The response of the host to the presence of pathogens after surgical intervention
o Suspicion
o Appropriate work up is essential
Signs and symptoms
o Fever, chills, night sweats, loss of appetite, red streaking, painful lymph nodes
Organisms
o Most common organisms (Staphylococci, streptococci, gram (-) bacilli)
o Anerobic organisms
o Look for the signs & symptoms –> Intense pain, foul smelling, gas, necrosis, brownish/black discharge
Factors affecting the host
Factors compromising the immune system
o Extremes of age, physical status (obesity)
o Dehydration, shock, malnutrition/vitamin deficiency, anemia
o Infection at remote site, recent antibiotic therapy
o Uncontrolled diabetes or other systemic diseases
o Steroid therapy or immunosuppression (drugs or disease)
o Anergy (to skin tests)
Factors that influence contamination
- Perioperative hospitalization, antiseptic agents, hand preparation (time, agent, gloves)
- Preoperative skin preparation (shower, shave), perspiration, surgical supplies and equipment
- Lack of strict instrument sterilization, drapes (gowns, materials, technique)
- Moisture (tissue, fluids, irrigation), breaks in sterile technique, long hair/beard uncovered
- Talking to scrub team members, movement or talking by non-scrubbed personnel
- Number of personnel in operating room, duration of surgery, dose of invading organisms
- Virulence of invading organisms
Factors that enhance the wound as a CULTURE medium (good for infection, bad for the patient)
Ischemia
- inadequate supply, vessel disruption, tourniquet of long duration, epinephrine (high concentration), tissue trauma, edema
Tissue necrosis
- rough handling, dessication, electrocautery
Tissue type
- skin, adipose, muscle, tendon, ligament, fascia
Foreign bodies
- sutures, prosthetics, fixation devices
Dead space
- hematoma, seroma
Incubation period
Treatment for post-op infection
- Decompression
- Drainage
- Debridement
- Antibiotic therapy
Osteomyelitis
- Hematogenous (less likely in healthy – more common in infants/elderly population)
- Contiguous (sharing a common border; touching, next to each other)
Organism
- Staphylococcus
- Streptococci
- Patient gets prophylaxes
o Mixed gram+ & gram-
o Just gram -
Other causes of post-op pain
- Suture reaction - This is just an irritation
Case study
o CC: Swollen, painful left great toe s/p nail procedures
o HPI: Pt initially treated for Left hallux medial and lateral infected ingrown toenails with oral antibiotics and partial nail avulsion without complications. Three weeks later, medial and lateral Winograd procedures and medial subungal exostosis was performed at a surgery center. Recovery uneventful, until 2 weeks post op when she presented with warm, edematous, painful left hallux with small amount of purulent type drainage on bandage.
o PMH: Type II DM (7 years), HTN
o PSH: Tonsillectomy, Left great toe Winograd
o Meds: Altace, Norvasc, Glucotrol, Actos
o All: Tetracycline, Iodine dyes
o SH: Occasional Alcohol, Denies Tobacco, SICU Nurse
o FH: DM, CAD, HTN
o ROS: Denies N/V/F/C, SOB, CP Blood glucose average 130’s (her normal range)
Physical exam
General
o Well nourished, well developed, A&O x 3
Vasc
o Pulses +2/4 DP, PT, CRT
Follow up 1 week
o Mild drainage with dressing changes o Moderate pain – controlled o No purulence, no malodor, no ascending lymphangitis o Hallux deep purple color o X-rays taken
