Postoperative Fever in Gynecologic Patients

1
Post-operative Feverin Gynecologic Patients

• Presented by Caleb J. Trent, M3
• For Dr. Todd Tillmans
• OB-GYN/GYN-ONC rotation

2
Why is fever so important?

• Peri-operative and post-operative infections are
  usually determined clinically and confirmed
  microbiologically1
• Identification of infection is usually initiated
  in response to a clinical signal FEVER
• Fever is a common post-operative complication
  after benign gynecologic surgery 40 to 902
• The etiology and final treatment of the fever may
  be the most frustrating

3
Definition of Fever

• The presence of a temperature greater than or
  equal to 100.4F on two occasions at least four
  hours apart, excluding the first 24 hours, OR one
  temperature greater than 101.5F3
• Infectious (IF) or non-infectious (NIF) fever
• Infectious (30-40) bacterial, fungal, viral,
  etc.
• Non-infectious (50-92) part of the normal
  response to insult and injury (actually more
  common), due to radiation, etc.4
• Fever is often a challenging foe

4
Pathogenesis of Fever

• Caused by circulating pyrogens
• Pyrogens can be5
• Exogenous Gram-negative bacteria endotoxin
• Endogenous cytokines
• Culprits are TNF-a, INF-?, IL-1, and IL-6
• IL-6 levels correlate logarithmically w/ post-op
  peak body temperature6
• IL-1 is crucial in the febrile response to
  injured tissue
• TNF-a, INF-?, and IL-6 are pro-inflammatory

5
Approach to a febrile post-op patient7

• Good thorough history and physical are KEY
• Ask yourself if this fever is infectious or not?
• Regardless of the origin, treat the fever!!
• A fever of non-infectious origin?
• Normal part of recovery process, absence may be
  bad
• Due to systemic inflammation
• If febrile patients seem to have infectious
  sources for their fevers based on HP, suspect
  the following areas for infection

6
Urinary Tract Infections

• Most common site of infection in surgical
  patients
• Incidence is 47 to 208
• Defined as growth of gt105 organisms/ml of urine7
• Often d/t catheter, usually confined to lower GU
• PPV of UA is zero in diagnosing UTIs8
• Treatment
• Antibiotic therapy
• PCNs, cephalosporins, sulfas, fluroquinolones,
  and nitrofuran
• Hydration in patients without contraindications

7
Respiratory Infections

• Uncommon in gynecologic surgery patients7
• Pneumonia and effusions are some of the more
  common respiratory infections7
• Risk factors are
• COPD or underlying airway disease
• Prolonged immobility or atelectasis
• Body habitus and individual susceptibility
• Culpable organisms
• Gram positives AND Gram negatives
• CXR of little value if no clinical indications8

8
Phlebitis/Vascular Infections

• Infection from intravenous (IV) catheters occured
  in 25-35 of patients, less now7
• Prevention changing IVs often, TEDs/SCDs
• Suspect problems if patient has FEVER, pain,
  redness or palpable cord
• DVT/PE typically present with low-grade fever
• Treatment is Antibiotic therapy, Anticoagulation
  Ambulation, and only rarely, excision of the
  infected/blocked vessel depending on case

9
Wound Infections

• 2nd most common infectious post-op complication8
• Wound infection rate increases with duration of
  stay in facility8
• Symptoms usually occur after the 4th POD7
• Prevention is good closure and good technique
• Management is usually mechanical (delayed primary
  wound closure, debridement, wet to dry) and
  antibiotics7

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Tissue Infections

• Two big threats cellulitis and necrotizing
  fasciitis7
• Cellulitis above the belt is typically
  Staph/Strep below the belt suspect Gram neg and
  anaerobes
• Necrotizing fasciitis is not common, but serious
• Hyaluronidase and lipase in subcutaneous space
  destroy the fascia and adipose tissue
• No muscle involvement no Clostridia
• Can cause sepis, shock, acid-base issues, MOF
• Suspect Enterobacter, Pseudomonas, and anaerobics

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Intra-abdominal/Pelvic Abscesses

• Occur in cases where sites were improperly
  drained or w/ hematomas7
• Usually polymicrobial aerobic Gram negatives
  and Bacteroides anaerobes
• Suspect if fever persists and WBC steadily rise
• USG is okay, but CT is often more sensitive8
• Treatment is ampicillin, gentamicin and
  clindamycin.

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Points about febrile post-op workup8

• BMI may be an indicator of post-op fever
• Due to increased potential for fat necrosis
• Fever is an indicator of increased hospital stay
• Preop antibiotics decrease post-op fever, but it
  does not seem to be agent dependent
• WBC count is not as reliable an indicator as we
  think it is
• The workup is extensive and not always positive
• Tighten criteria, do a good HP, and treat those
  at risk for fever

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References

• 1 Souka, Fink, et al, ACS Surgery Priniciples
  and Practice, (2004 ) Chapter 14 Clinical and
  Laboratory Diagnosis of Infection by Evans, D.
  C.and Meakins, J.L. pp. 1260-1267
• 2 Salom E.M., Schey D., et al., The safety of
  incidental hysterectomy at the time of abdominal
  hysterectomy, Am Journal of Obstetric Gynecology
  189 (2003), pp 1563-1567.
• 3 Ahaya S.N., Flood K., et. al., The Washington
  Manual of Medical Therapeutics (30th ed.),
  Lippincott Willliams and Wilkins, Philadelphia
  (2001).
• 4 Klimek J.J., Ajemian E.R., et al., A
  prospective analysis of hospital acquired fever
  in obstetric and gynecologic patients, JAMA 247
  (1982), pp. 2240-3343.
• 5 Daveatelis D., Wolpe S.D., et al., Macrophage
  inflammatory protein a prostaglandin-independent
  endogenous pyrogen Science, 243 (1989)
  pp.1066-1068.
• 6 Wortel C.H., van Deventer S.J., et al.,
  Interleukin-6 mediates host defense responses
  induced by abdominal surgery, Surgery 114 (1993),
  pp. 564-570.
• 7 Berek, Adashi, Hillard Novaks Gynecology
  (1996) Chapter 19 Perioperative Evaluation and
  Postoperative Management, pp 563-569.
• 8 Schey D., Salom E.M., et al., Extensive fever
  workup produces low yield in determining
  infectious eitiology, The American Journal of
  Obstetrics and Gynecology 1925 (2005), pp.
  1729-1734.

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USMLE Step II Common Causes?

• WIND lungs are often the 1o source in the first
  48 hours
• WOUND infection at the surgical site
• WATER check IV access site for signs of
  phlebitis or edema
• WALK DVT can develop due to pelvic pooling or
  restricted mobility related to pain and fatigue
• WHIZ UTI is possible if cath was used
• WONDER DRUGS drug fevers

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Common systemic causes of post-operative
infection

• Lack of perioperative prophylaxis
• Immuno-compromised host
• Chronic or severe disease/poor nutrition
• Pre-existing focal or systemic infection
• Contamination of surgical field/poor technique