You are paged about a fever of 101.8°F in a 58-year-old man who is postoperative day 3 from a colostomy reversal. He is normotensive, his heart rate is 110, and while he is oxygenating well, he is breathing at 22 breaths/min. His past medical history is notable for COPD and his preoperative medications include 4 mg of oral prednisone taken daily. This is the first fever that he has had since the operation and his nurse is requesting that you order Tylenol. When you evaluate the patient at the bedside, he states that he “doesn’t feel too well.”
1. Based on the timing of the patient’s fever, would you be surprised if he is ultimately diagnosed with a pneumonia?
2. What history and physical exam findings will help to confirm the diagnosis?
A surgical fever is defined as a temperature greater than 101.5°F or 38.5°C. The major etiologies for postoperative fever that should always be considered include atelectasis, pneumonia, urinary tract infection, intra-abdominal infection or leak, wound infection, and deep venous thrombosis. Other processes such as malignant hyperthermia, superficial thrombophlebitis, C. difficile colitis, endocarditis, and line infections should also be considered given the appropriate circumstances.
It is often helpful to categorize these various etiologies by the postoperative day on which they are most likely to occur (see Table 39-1). It is, however, important to note that any of these processes can occur on any postoperative day.
- POD 0 to 1: There are multiple possible causes of fever on POD 0 and 1, including malignant hyperthermia, necrotizing wound infection, systemic inflammatory response syndrome (SIRS), and atelectasis. While atelectasis has traditionally been considered the most common cause of fever on postoperative day 1, it is a diagnosis of exclusion and more serious etiologies should be ruled out. These include malignant hyperthermia that is most likely to manifest in either the operating room or the PACU, and a severe necrotizing wound infection. Therefore, even if atelectasis is suspected, the patient should be examined and the dressing should be removed in order to inspect the wound. Within the first 48 hours post surgery the dressing removal should be done in a sterile fashion.
- If more serious causes have been ruled out, the fever is most likely due to a postoperative SIRS response or atelectasis. If you suspect the latter, then treatment is simple and consists of aggressive incentive spirometry, encouraging coughing and deep breathing, and ambulation.
- POD 3 to 4: Classically, this is the time that urinary tract infections and pneumonias first manifest. Again, however, it should be noted that this time frame is not absolute. For example, an aspiration pneumonia related to intubation will probably present earlier, and a patient may present to the hospital already having a UTI. Nonaspiration pneumonias typically result from inadequate pulmonary toilet, ...