Fever post laparotomy

Question 1

You have been asked to review a 72-year-old woman on the surgical ward because of fever. She had an emergency laparotomy for perforated duodenal ulcer the previous day. She has a temperature of 38C, BP 130/70mmHg, PR 82 BPM. She is currently having intravenous Amp, Gent, and Metro. What would be the most appropriate management?

Answer 1

Impression
Given this patient is day 1 post-op, I am provisionally concerned that this is a pyrexial response to surgery. Lack of concerning features for systemic infection from the stem, and fever <39C.

Of course, I would want to rule out the potential for sepsis/other infective causes, however these are less likely to be post-op complications given the time-frame.

Ddx to exclude include; (5Ws of post-op fever)

• sepsis
• anastomotic leak/perforation
• surgical site infection
• other infective; UTI, pneumonia (HAI), lines, surgical site

Non-infective

• PE, ACS, MI, DVT
• atelectasis

The most appropriate management;

• primary survey, thorough Hx/Ex/Ix to exclude Ddx, including a full septic work-up
• send for senior help, initiate appropriate definitive and supportive mx in consultation with treating team

Question 2

Fever post-laparotomy - Assessment

Answer 2

Assessment
Would call for senior help / surgical review
Begin A to E assessment
A, B as per normal, expect nil pathology
C: IVC insertion, bloods, septic work-up, BP/HR monitoring, fluids and empirical ABx as indicated
D to G as per normal

Question 3

Fever post-laparotomy - History

Answer 3

History
Review op notes for any complications/ details of the procedure, note ongoing management plan for patient as well as any relevant NFR/ACD documentation
- Sx: pain, bowel motions/wind, infective sx,
- REDS: urinary sx, respiratory sx, sx of DVT/PE (utilise wells criteria)
- PSHx, PMHx, Medications, allergies, last meal,
- medications review

Question 4

Fever post-laparotomy - Examination

Answer 4

Examination

• General appearance + vitals (confirm pyrexic)
• abdo examination: assess surgical site, any lines,
• cardiorespiratory
• urine output

Question 5

Fever post-laparotomy - Investigations

Answer 5

Investigations
Often not indicated if clearly simply a pyrexial response
if persisting;
- septic work-up: Urine MCS, sputum MCS, CXR, blood cultures, LP, stool samples, wounds/lines swab and MCS
- other bloods: FBC, UEC, LFT CRP/ESR - compare to previous blood results.
- Imaging: CT abdo/pelvis with IV and oral contrast

Question 6

Fever post-laparotomy - Management

Answer 6

Management

• contact treating team and inform, request review
• escalate to ID if concerns for infection, she is on appropriate empirical ABx - just change to targeted therapy once sensitivities return

Supportive

• anti-pyretics
• analgesia as appropriate
• anti-emetics
• fluids and electrolyte support
• cease unnecessary meds, regular obs

Definitive

• depends on the clinical picture, if pyrexial response then doesn’t need any definitive mx only supportive
• empirical ABx for ?sepsis/infection and then directed ABx after return of investigations. Ideally take cultures prior to starting empirical ABx therapy.
• may require surgical approach if anastomotic leak, intra-abdominal abscess/infection, or other surgical complication