Postoperative Fever Flashcards
Why is there such a huge risk of postoperative infection after a total joint replacement?
Prosthesis provides culture medium
What are the differential diagnoses for a postoperative fever?
Infective - UTI - Pneumonia - Wound infection - Septic arthritis Non-infective - Transfusion - DVT/PE - Allergic reaction - Medication reactions - rare
What are the “big five” causes of postoperative fever?
Surgical site - late IV sites - probably most common cause UTI Pneumonia DVT - 5-7 days post-op
What are the possible causes of fever between days 0 and 2 post-op?
Mild fever (<38) - Common - Likely inflammatory response to iatrogenic wound Tissue damage and necrosis at operation site Haematoma Atelectasis Specific infections related to surgery Blood transfusion Drug reaction Infection prior to surgery Malignant hyperthermia - very rare
What are the possible causes of fever between days 3 and 5 post-op?
Bronchopneumonia Sepsis Wound infection Drip site infection/phlebitis Abscess formation DVT UTI
What are the possible causes of fever after 5 days post-op?
Specific complications related to surgery
Wound infection
Distant sites of infection
DVT/PE
IV sites
Drug reactions
Other nosocomial infections, especially if in ICU
What are the possible causes of fever one month after surgery?
Surgical site
Viruses and transfusion; eg: CMV
What does spiking temperatures suggest?
Abscess
How are IV sites, arterial lines, central lines, and drain sites assessed for possible source of postoperative fever?
Inspect all sites
Note date inserted
When were they changed?
How are drain sites associated with postoperative fever?
May get infected
Indicator of deep infection - see purulent fluid
What are the signs of central line-associated bloodstream infections?
Usually have no localising signs
What should be assessed if you suspect a urinary tract infection as the source of the postoperative fever?
Was a catheter used? Is it still in situ?
Is the catheter blocked?
What colour is the urine?
Does asymptomatic bacteraemia in catheterised patients need treatment?
No
What signs can be seen in the chest that may indicate it as the source of the postoperative fever?
Crepitations
Dullness to percussion
What assessment is done in the legs to determine if they could be the source of postoperative fever?
DVT - Swelling - Tender calf - No signs, but high risk Check thromboprophylaxis - TEDS - Clexane - Pneumatic calf compressors Investigate with US
What is the usual anti-Staphylococcus cover in a postoperative patient?
First generation cephalosporin
Whether you do/don’t start with vancomycin depends on several factors
- Get ID input
- Consider vancomycin use
What are the host risk factors for a surgical site infection?
Age Obesity Malnutrition Diabetes Steroids Smoking Infection at another site Skin carriage of S aureus
What are the environmental risk factors for a surgical site infection?
Type of surgery Wound class Surgical technique Operation duration Hair removal Skin prep used Hypothermia Inadequate surgical Abx prophylaxis - Choice - Timing Theatre traffic
What should you consider in anyone with a positive blood culture for S aureus, especially if they’re not responding to antibiotics?
Endocarditis > do transoesophageal echocardiogram (TOE)
Why is general anaesthesia preferred over spinal anaesthesia in a patient returning to theatre in the case of postoperative fever?
Spinal anaesthesia could introduce bacteria into CSF
When does ventilator-associated pneumonia (VAP) develop?
More than 48 hours after intubation
What are most cases of hospital acquired pneumonia related to?
Micro-aspiration
These patients often can’t cough properly because of neurological impairment
What are the common organisms causing hospital acquired pneumonia?
Most commonly, aerobic Gram -ve bacilli - E coli - Klebsiella - Enterobacter - Pseudomonas S aureus, including MRSA
In whom are resistant pathogens more likely in the context of hospital acquired pneumonia?
VAP ICU Longer hospital stay Previous Abx Immunosuppression
How can hospital acquired pneumonia be avoided?
Avoid excessive sedation
Mobilise - sit out of bed
Avoid H2 blockers and PPIs, unless ulcer risk
