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Fever post operative (gynaecological)

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Fever Post Operative (Gynaecological) Prof. M.C.Bansal. Founder Principal &controller; Jhalawar Medical College Jhalawar. Ex. Principal & Controller; Mahatma Gandhi Medical College & Hospital; Sitapura, Jaipur
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Page 1: Fever post operative (gynaecological)

Fever Post Operative (Gynaecological)

Prof. M.C.Bansal.Founder Principal &controller; Jhalawar Medical College Jhalawar.Ex. Principal & Controller; Mahatma Gandhi Medical College & Hospital; Sitapura, Jaipur

Page 2: Fever post operative (gynaecological)

Fever

Definition Fever is the rise of normal core temperature of an individual that exceeds the normal diurnal variation and is accompanied by an increased hypothalamic setup.

Diurnal Variation in 18-40 years of age— Mean Temperature : 36.8+/- 0.4 C (98.2+/- 0.7 F ). ;being low at 6 AM

–36.2 c or98.0 F and highest at 4-6pm in the range of 37.7 c or 98.9 F.

Temperature > 38C(100.4 F )recorded at two occasions at the interval of 4hrs apart , excluding 1st 24 hrs after surgery or any one temperature recording more than 38.6 c ( 101.5 F ) is taken as post operative fever.

Incidence varies widely from 14-91 % .

THIS MAY BE INFECTIOUS / NONINFECTIOUS.

80-90 % patients developing temperature with in 24hrs after operation are not infected , but patients who develop fever on /5th post operative day(80-90 % ) usually have commonly identifiable infection .

Infection is definite if it develops after 2days of surgery.

Page 3: Fever post operative (gynaecological)

Manifestation Of Fever

Shivering; Chills– may be alternate to feeling of

hot; General Malaise; Somnolence; Anorexia; Arthralgia , myalgia, skin sensitivity

to touch ; Absence / presence of sweating; Skin rash; Increased pulse rate / BP.

Page 4: Fever post operative (gynaecological)

Time Related Causes OF Postoperative Fever (4 Ws)

Time related causes described here are only guidelines and do not serve as rule. On many times there is temporal overlap in the causes described –5Ws

POD 1-2 Wind (respiratory ) atelectasis develop within 24-48 hrs . Aspiration pneumonia, ventilator associate pneumonia .

POD3-5Water—UTI, specially in catheterized patient. POD5-6 W(veins) , wings , walking –DVT , Iv cannula

site plebitis , IM, injection abscess. POD5-7 wound– check for wound infection ,drainage ,

alternate sutures removal , swab culture and diagnose serious problem such as necrotizing fascitis and peritonitis due to intestinal leak ( internal wound).

POD 7+ Wonder if ? Drug induced—drug reaction , drugs used intra / post operative / transfused blood or blood products , anti inflammatory agents etc.

Page 5: Fever post operative (gynaecological)

Miscellaneous Causes Of Postoperative Fever

Sinusitis Thyroid disorders Meningitis

Seasonal infections--Pharyingitis, Swine Flue malaria , Dangu etc.

Adrenal Insifficiency Medication s

Infected central catheter

Pheochromocytoma **Drug Fever associated with skin rash/ eosinophilia--

Ventilator –associate Pneumonia

Myocardial infarction ----Antiepileptics—phenytoin,

Infected Hematoma Pulmonary Embolism --- Antibiotics beta lectum s, sulphas , piperacillin ,tezobactam.

Acute gout / flare-up . Neuroleptic malignancy tumor

---Anti inflammatory drugs – Endomethacin,

Acute Alcohol withdrawal

Intra cranial pathologies --- Intra operative drug – Succinyl chloride

Page 6: Fever post operative (gynaecological)

Life Threatening Causes of Early POF

Malignant Hyperthermia rare dominantly transient genetic disorder triggered by administration of succinyl

chloride occurs with in ½ an hour of its administration , but may

persist for < 10 hours. BP unstable , rise in heart rate , fever may shoot up to

41-42 C . Muscle rigidity , acidosis, hypoxia cardiac arrhythmia

develops . Treatment is to stop all anesthetic drugs , hyper

ventilation, O2. Initiate cooling , and diuresis to prevent precipitation of

myoglobin . Inject dantrolene sodium and procainamide.

Page 7: Fever post operative (gynaecological)

Life threatening POF---

Adrenal Insufficiency- Typically occurs in patient who are taking corticosteroids for a long duration ; owing to suppression of endogenous steroids (hypothalmo- pituitary –adrenal axis ). Fever , refractory fall in BP may develop . Steroid supplementation in time will resolve the problem.

Pulmonary embolism usually presents as hemodynamic sudden post operative hemodynamic instability and collapse . Fever, although uncommon , may be present.

Alcohol Withdrawal frequently presents with fever , prompt recognition and treatment prevents excessive morbidity and mortality.

Page 8: Fever post operative (gynaecological)

Life threatening POF---- Myo necrosis – common due to wound infection Clostridium species or group A Strepto –cocci. It is a surgical emergency patient presents with shock, tachycardia, fever and septicemia

with in 24 hours after operation. Di9agnosis is easy if dressing is opened and wound is

examined . Thin brownish copious malodorous discharge is present . Take swab for culture and sensitivity.

Skin may be discolored , subcutaneous crepitations , bullae formation .Patient has severe pain, restlessness and local tenderness. If not treated immediately patient may have vascular collapse, acute renal failure , haemoglobinuria and jaundice.

Wide excision of all infected and necrosed tissue , high dose of C. penicillin 20 lacs 6hrly after AST / tetracyclines is mandatory.

D/D – metastastic Myonecrosis from adeno carcinoma of bowel

Page 9: Fever post operative (gynaecological)

Life Threatening POF--- Necrotizing Fascitis occurs due to wound infection by poly microbes–

haemolytic strepto cocci, staphylococcis anaerobes or mixed bacteria.

Necrosis of superficial fascia results ; underlying muscle are spared .Toxicity is more severe than WBC counts / fever / hypothermia , hypotension ,tachycardia and lethargy.

Locally the wound is dusky with subcutaneous edema , induration, crepitations , hyperesthesia and bullae formation in skin .

Haemoconcentration ,hypokalemia , hemolysis, hyperbilrubinaemia develop at faster rate.

Hepatic, renal pulmonary insufficincy soon develop and patient is in state of septic shock.

Page 10: Fever post operative (gynaecological)

Life threatening –POPF ---necrotizing Fascitis----

Aggressive treatment started as in cases of major degree burns.

Predisposing factors include --- diabetes , obesity, trauma , alcoholism , immunosuppressive state, hypertension , peripheral vascular disease , IV drug abuse and addiction .

A wide excision and debridement / re debridement is done .

Iv fluid therapy and nutrition with correction of electrolyte imbalance and broad spectrum antibiotics are started ; to be changed as soon the c/s reports are available.

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Life threatening POF ---

Intestinal Leak It occurs early / late from devitalized / crushed intestine during dissection from pelvic tumors / leaking anastomosis site.

Diagnosed by suspicion / flat plate abdomen in standing posture for gas under diaphragm.

Manage by -- exploratory laparotomy , repair of the damaged gut , peritoneal toileting and drainage , blood transfusion , antibiotics , resuscitation with fluid ,electrolytes minerals , vitamin supplementation . Ketoacidocis is prevented by ensuring adequate total parenteral nutritional therapy; till oral feeding is suspended .

Page 12: Fever post operative (gynaecological)

Approach to a patient with Fever In post operative period.

A care full review of history , investigations ,pre / intra , post operative sequence of events .

Through general physical, systemic and operative site examination , Consultation with physician / general surgeon / necessary investigations are the key points in prompt diagnosis of post operative fever.

An early , timely and appropriate diagnosis , immediate treatment helps in minimizing the mortality and morbidity

The presence of non infectious cause of fever does not exclude the possibility of infective reason as both may co –exist.

Page 13: Fever post operative (gynaecological)

Interpretation of complains--- Fever associate with diarrhoea and central abdominal

pain---- Enterocolitis due to c Clostridium difficile. Calf pain & tenderness--- DVT . Cough with sputum , breathlessness ---Pulmonary

infection . Urinary frequency , dysurea, haematurtia , urgency

supra pubic and loin pain ----UTI / Pyelonephrytis. Site of pain ---helps in localizing the infection ---wound ,

IV cannula , catheter site . Intense pain at wound , restlessness with fever may be due to clostridium myonecrosis.

Fever with delirium ---- acute alcohol withdrawal . Rigors and chills ---atelectasis , malaria / pyelonephritis. Headache , projectile vomits, stiff neck----Meningitis. Pain at IM injection site-----injection abscess

Page 14: Fever post operative (gynaecological)

Pre operative conditions –may contribute to POF

Previous H/O pyrexial illness ---Malaria, TB, Sinusitis ,UTI ,pulmonary disease( empyema, plueral effusion bronciectasis ).

Local infection--- vaginal vaginosis, cervicitis , infected fibroid / malignant legion/ decubitous ulcer in case of prolapse , skin infection at the site of skin incision etc

Family or Personal H/O malignant hype pyrexia , thyroid disorder , IV drug abuse , alcohol / tobacco intake , obesity , Pre operative transfusion of blood , fluids . Drugs and drug reaction.

Patients who are more susceptible ---- obese , diabetic , Immuno compromised , taking chemo / radiotherapy , Corticosteroids , debilitating disease, malnutrition , renal / liver insufficency , extremes of age ( old aged ) and BP, cardiac valular disease.

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Review the details of surgery Done

Date of surgery ---exact Post operative day and onset of fever .

Its type and duration , Use of Implants—mesh Type and duration of preoperative antibiotics given . Pattern of onset of symptoms on which Post operative

day . Existing symptoms prior to surgery , investigations / any treatment given and its response .

Any complication during operation / anesthesia. H/O prolonged ventilation . Left over packing , swabs or instruments / poor

debridement / excision of infected , nacrosed tissue / un recognized / over looked injury to gut.

Page 16: Fever post operative (gynaecological)

wound examination

Monitor vital parameters . If tachycardia is out of proportion to rise in temperature

is an ominous sign as in severe sepsis , associated with hypotension and oliguria.

Tachypnoea --- pulmonary cause . Pattern , trend and its flctuation should be noted. Detailed examination of wound– color of skin ( dusky ,

red, blue/black , indurations , discharge(amount, color , odor , frothing ) , tenderness, necrosis of edges, bulla , crepitations.

if any ,silent dehiscence of wound , presence of cellulitis , fascitis, abscess, haematoma, gas gangrene hyperaesthesia, spreading erythematous streaks.

Page 17: Fever post operative (gynaecological)

Wound Examination ---

In early stage of wound infection, there is swelling ,warmth ,redness peri wound edema and increasing tenderness .

Later there are more signs of stephylococcal infection ---maximum erythema and fluctuation ; while with enteric organisms tenderness is more and erythema is minimal.

Other signs of infection like fever , malaise . Leucocytosis ,tachycardia/ chills may develop.

Lymph node draining the infected are may also be involved---to be examined.

Page 18: Fever post operative (gynaecological)

Infected wound with inflammation of margins

Page 19: Fever post operative (gynaecological)

Necrotizing Fascitis

Page 20: Fever post operative (gynaecological)

Delayed healing of the surgical wound

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Partial superficial dehiscence due to local infection

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Facies in acute peritonitis

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Systemic Examination

All intravenous puncture sites with/ without cannulae along with all drain sites ---to be seen for any evidence of infection as thoroughly as wound site examination.

Nose , throat , ear, chest for infection ---sinusitis , chronic SOM, atelectasis/ consolidation/ collapse of lung / pleural effusion / empyema , Pulmonary embolism .

Abdominal Examination---hepato splenomegaly and tenderness, abdominal distension , tenderness (localized or general ),rebound tenderness , free fluid , characters of intestinal sounds , evidence of peritonitis , intraperitoneal abscess, foreign body , peri nephric abscess, subdiaphragmatic abscess , pelvic abscess(PR / PV if needed needling).

Page 24: Fever post operative (gynaecological)

Systemic Examination-----

Tenderness over renal , bladder indicate UTI.

Cardiovascular examination----alular disease (SABE)

CNS--- Neck stiffness , neck rigidity , kerning's sign +vet , photophobia , altered level of consciousness ----- exclude meningitis / cerebral infection.

Page 25: Fever post operative (gynaecological)

Chest Examination

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Blood Investigations----

Bacteriological assessment--- Blood culture , urine culture , wound swab

culture sputum/ aspirated pleural fluid / peritoneal

fluid . CSF , if LP done Needle aspirate from indurated area/

sp[reading cellulitis surrounding wound / enlarged lymph node , culture from cannula and catheter on removal.

Stool culture. It should be for identification of Pathogen and their sensitivity to drugs .

Page 28: Fever post operative (gynaecological)

Radiological Investigations

Chest X ray --- PA view --- Pneumonia, etelactasis, pleural effusion , pleural thickening , metastasis , Lung collapse. Consolidation , tuberculosis. Chronic bronchitis , cardiomegaly , pulmonary embolism. Pericardial effusion . Mediastinal mass etc.

Flat plate Abdomen --- multiple fluid levels and distended intestinal loops incases of peritonitis., air under diaphragm in cases of intestinal perforation. displacement of gas filled intestinal loops by foreign body, pelvic abscess/ free fluid in peritoneal cavity.

Page 29: Fever post operative (gynaecological)

Radiological Investigations--- USG Whole abdomen and pelvis ----amoebic

liver abscess, spleen and liver enlargement, renal and peri nephric pathology , pelvic abscess, hematoma, forgotten lepard /instrument . Doppler can help in identifying thrombosis.

CAT & MRI can identify abscess , foreign body , hematoma and other lesions .

ECG and Echocardiography ---- myocardial infarction , pulmonary embolism , intra cardiac thrombus , valvular disease .

Page 30: Fever post operative (gynaecological)

Lobar pneumonia (lateral View)

Page 31: Fever post operative (gynaecological)

Viral Pneumonia

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CT Scan of Lung Abscess( right lower lobe)

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CT Scan of Bronchiectasis

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Pulmonary Embolism A CT Scan

Page 35: Fever post operative (gynaecological)

Post LSCS Incisional Dehiscence with gas and parametrial abscess

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Visual hyper-peristalsis in intestinal obstruction

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Multiple fluid levels in intestinal obstruction

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Air under diaphragm in intestinal perforation

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Glass ground appearance in peritonitis

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CT SCAN of pelvic abscess

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CT SCAN – amoebic liver abscess( a cause of fever)

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Deep vein thrombosis- a cause of post- operative fever

Page 43: Fever post operative (gynaecological)

Most common Sites OF Infections and Their screening

Infection / pus collection may be located My be ---- endogenous, exogenous ( nurse / doctor , instruments , visitors , aseptica conditions of Hospital )

1. Intracranial --thorough History , CNs examination , LP , Brain scan---Cat / MRI with dye or without dye.

2. Above Oral Diaphragm –sinusitis, pharyngitis ,Ch. SOM , Parotid abscess , Tonsillitis ---ENT checkup , throat swab culture .

3. Above Thoraces -abdominal Diaphragm—cardio –respiratory system—History taking , Chest examination , X ray chest , sputum examination, culture , ECG and echocardiogram.

Page 44: Fever post operative (gynaecological)

Most common Sites OF Infections and Their screening----

4. Above Pelvic diaphragm --- Symptoms and signs on abdominal ,pelvic , PR , p v examination . Wound examination , flat plate X Ray in standing position , CBC , wound swab culture, USG, TVS , Urine examination and culture , Blood culture , catheter / drain / canola site examination , and culture .

5. In between Pelvic and perineal diaphragm ---- local symptoms of deep seated pain in pelvis and perineum ---local examination --- pelvic and Perineal USG.

6. other sites--- gluteal region , Calf muscles for DVT , Epidural / spinal anesthesia site .

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Common sites of pus pockets in the abdomen

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Page 47: Fever post operative (gynaecological)

Management It is directed at the cause . General Measures---Replacement of fluid loss ,

maintain input out put , electrolytes, nutrition , avoid development of acidosis, control fever below 1ooF by antipyretics( paracetamol / N-SAIDs and Aspirin ) , cold sponging.

In patient to have an infection , examination to localize the site and source of infection , culture for identification of offending pathogens / their sensitivity to antibiotics --- and appropriate therapy in optimal doses is must.

Surgical intervention may be required in the form of wound debridement , excision of infected wound or diseased organ to eliminate the constant source of infection and drainage of pus collected at any site .

Page 48: Fever post operative (gynaecological)

Frank pus in peritoneal cavity

Page 49: Fever post operative (gynaecological)

Pus pockets in peritoneal cavity

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Colpotomy to drain pus from the Pouch of Douglas

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Management ------

Exploratory Laparotomy when intra peritoneal lesion is suspected .

Septic pelvic Thrombophlebitis may develop 2-4 days postoperatively. Clinical signs may be unreliable ; can best be confirmed by Doppler USG / venography . Immediate heparinization and broad spectrum antibiotic therapy should be started.

Patient with septic shock need fluid resuscitation , inotopes , vasoactive drugs are needed to address impending myocardial depression . Mechanical Ventilation with high saturated oxygenation in ICU will be needed.

Page 52: Fever post operative (gynaecological)

Key points

Careful temperature recording and pulse monitoring will help in early detection of the fever.

Thorough review of each individual- right from the history, pre-op, intra-op, post-op clinical examination and relevant investigations will help to clinch the diagnosis.

Appropriate conservative/ operative management should be started as early as possible and if needed, second opinion from fellow colleagues- physician, surgeon and anesthetist, microbiologist should be sought.


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