Post-op - FEVER

Question 1

A patient is nervous about her surgery. Her adoptive parents are very supportive; they accompany her up until she enters the OR. She has just received her anesthesia. when the anesthesiologist notices her heart rate, respiratory rate, and temperature rising. Soon, her temp is up to 106 degrees and her muscles become rigid. The monitor shows an increased PCO2 production.

1. Likely diagnosis
2. Treatment
3. Complications

Answer 1

1. Malignant hyperthermia (autosomal dominant)
   - s/sx due to hypercatabolic state (very high temps, increased HR, abnormally rapid breathing, increased CO2 production, increased O2 consumption, mixed acidosis, rigid muscles, rhabdomyolysis)
2. IV Dantrolene, 100% O2, correction of acidosis, cooling blankets
3. Myoglobinuria (–> acute kidney injury)

Question 2

A patient has a hysterectomy as well as a cystoscopic examination to rule out bladder injury from the procedure. About half an hour after surgery, she begins having chills with fevers spiking to 104-106 F. She denies pain out of proportion to what is expected.

1. Likely diagnosis
2. Dx
3. Tx

Answer 2

1. Bacteremia
   - w/in 30-45 min of invasive procedures (ex: instrumentation of urinary tract)
   - chills, fevers >104 F
2. BCx x 3
3. Empiric Abx

Question 3

The nurse calls because a patient has developed very high fevers as well as severe wound pain a few hours after surgery.

1. Likely diagnosis

Answer 3

1. Gas gangrene in surgical wound
   =myonecrosis (large blackened sores), gas production (loud, distinctive crepitus), sepsis –> rapid progression to toxemia, shock
   -rare
   -s/sx: severe wound pain & very high fever w/in hours of surgery

Question 4

Possible diagnoses for mild-moderate fever in post-op patient, by post-op day (POD):

Answer 4

Sequentially in time:

• Atelectasis (POD1) - likely NOT causal; old wives’ tale?
• PNA (POD3, if atelectasis isn’t resolving)
• UTI (POD3)
• DVT (POD5)
• Wound infection (POD7)
• Deep abscess (POD19-15; subphrenic, pelvic, subhepatic)

Question 5

A patient had surgery yesterday and today has developed a slight cough and difficulty breathing. She has a slightly increased temperature. On exam, there are bilateral coarse breath sounds towards the bases of the lungs. CXR shows no e/o pneumonia but does show some bibasilar opacities.

1. Likely diagnosis
2. Dx
3. Tx

Answer 5

1. Atelectasis
   - not cause of elevated temps, but often seen at same time as elevated temps
   - POD1
2. Dx: r/out PNA etc. (CXR)

3. Tx: 
Improve ventilation (deep breathing & coughing, postural drainage, incentive spirometry) 

Ultimate tx: bronchoscopy

Question 6

A day after surgery, a patient is found to have some atalectasis but refused to do any treatments. Three days after surgery, a patient develops fevers up to 103.0 F, cough, and shortness of breath. He has crackles in his left lower lung. His vitals show increased HR & RR, and decreased SPO2. CXR show an infiltrate in the left lower base.

1. Likely diagnosis
2. Dx
3. Tx

Answer 6

1. LLL Pneumonia
2. Dx:
   CXR: infiltrates
   Sputum cultures
3. Tx: Abx

Question 7

A patient presents with fevers around 102 F three days after surgery. Pneumonia is ruled out.

1. What other diagnosis is likely causing a fever on POD3?
2. Dx
3. Tx

Answer 7

1. UTI
2. UA, UCx
3. Abx

Question 8

A patient calls in five days after surgery due to leg pain and swelling. His wife took his temperature, which is around 101.6 F.

1. Likely diagnoses
2. Dx
3. Tx

Answer 8

1. DVT
2. Doppler studies of deep leg & pelvic veins
3. Anticoagulate w/heparain

Question 9

A patient presents for his 1 week follow after surgery. He is found to have a fever of 101.4 F. His surgical wound is red, warm, and tender.

1. Likely diagnosis
2. Dx
3. Tx

Answer 9

1. Cellulitis +/- abscess
2. Dx:
   PE
   US if needed to assess for abscess
3. Tx:
   Abx +/- I&D if absces

Question 10

A patient presents two weeks after surgery with fevers around 103 F as well as chills and loss of appetite. She also complains of shoulder pain on the left. She has cough, increase RR, and shallow respirations. The left lower lung area has diminished breath sounds and is dull to percussion. Her lower left ribs are tender.

1. Likely diagnosis
2. Dx
3. Tx

Answer 10

1. Deep subphrenic abscess
   (other deep abscess include subhepatic and pelvic)
   - start producing fevers around POD 10-15.
   -in the case of subphrenic abscesses, may affect breathing and cause referred shoulder pain, as well as systemic sxs.
2. CT scan of appropriate area
3. Percutaneous radiologically guided drainage