Postoperative Fever - StatPearls - NCBI Bookshelf 15/5/23 10:02

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Postoperative Fever
Tony A. Abdelmaseeh; Chaudhary Ehtsham Azmat; Tony I. Oliver.

Author Information and Affiliations

Last Update: December 3, 2022.

Continuing Education Activity

Postoperative fever is defined as a temperature higher than 38 C (or greater than 100.4 F) on two
consecutive postoperative days or higher than 39 C (or greater than 102.2 F) on any
postoperative day. Knowledge of differential diagnosis, as well as a systematic approach, proves
useful in narrowing down the differential diagnosis and instituting proper management. This
activity reviews the causes of postoperative fever and highlights the role of the interprofessional
team in its management.

Objectives:

Identify the common etiologies of postoperative fever.

Summarize the evaluation of a patient with postoperative fever.

Outline the treatment and management options available for postoperative fever.

Describe interprofessional team strategies for improving care and outcomes in patients
with postoperative fever.

Access free multiple choice questions on this topic.

Introduction
Postoperative fever is defined as a temperature higher than 38 C (or greater than 100.4 F) on two
consecutive postoperative days or higher than 39 C (or greater than 102.2 F) on any
postoperative day. Knowledge of differential diagnosis, as well as a systematic approach, proves
useful in narrowing down the differential diagnosis and instituting proper management.[1][2]

Fever, as a manifestation of sepsis, should be promptly identified and managed appropriately to

lower mortality rates in such cases.

Etiology
The timing strongly influences etiology.

Underlying conditions (e.g., immunosuppressed patients) may have a reduced

inflammatory response or reduced fever while at the same time having a serious infection.

Differential diagnosis includes infectious (e.g., nosocomial or surgical site infections) and
non-infectious (e.g., deep vein thrombosis, pulmonary embolus, myocardial infarction,
drug-related, transfusion-related, endocrine-related for example adrenal insufficiency or
thyroid storm) causes.

Fever is more likely to be due to infection as the time interval following surgery increases.

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Fever in patients may have more than one cause at the same time, and infectious and non-
infectious causes may coexist.

Epidemiology
Postoperative fever is very common. The exact incidence of postoperative fever is not known,
but the numbers are high. Estimates from different surgical procedures reveal that fever occurs
early in the postoperative period anywhere from 20% to 90% of patients. In the majority of these
cases, the fever usually occurs on the first or second day after surgery and has been linked to
benign causes. Postoperative fever is known to occur after all types of surgical procedures,
irrespective of the type of anesthesia. The fever also occurs in children and both genders.
Postoperative fever can occur after minor surgical procedures but is rare and depends on the type
of procedure. Overall, both abdominal and chest procedures result in the highest incidence of
postoperative fever.[3][4]

Pathophysiology
Systemic Inflammatory Response Syndrome (SIRS):

Four criteria include:

Temperature higher than 38 C or less than 36 C

Heart rate higher than 90 beats per minute

Respiratory rate greater than 20 per minute

White blood cell count greater than 12 x 10/L or less than 4 x 10/L

Two of the 4 criteria are needed to identify a patient with SIRS.

Two of the SIRS criteria plus a suspected source of sepsis are required to diagnose sepsis.

Sepsis plus organ dysfunction is consistent with severe sepsis.

Severe sepsis plus refractory hypotension (refractory to fluid resuscitation) is consistent

with septic shock.

Signs of Organ Dysfunction

Systolic BP less than 90 mm Hg or mean arterial pressure less than 65 mm Hg.

Drop in BP greater than 40 mm Hg (especially in hypertensive patients)

Lactate greater than 2 mmol/L

Urine output less than 0.5 mg/kg/hr for 2 consecutive hours

Drop in Glasgow coma scale (GCS) or abbreviated mental test scores

History and Physical

Immediate Fever

Fever occurs immediately after surgery or within hours on postoperative days (POD) 0 or 1.

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Malignant hyperthermia: high-grade fever (greater than 40 C), occurs shortly after
inhalational anesthetics or muscle relaxant (e.g., halothane or succinylcholine), may have a
family history of death after anesthesia. Laboratory studies will reveal metabolic acidosis
and hypercalcemia. If not readily recognized, it can cause cardiac arrest. The treatment is
intravenous dantrolene, 100% oxygen, correction of acidosis, cooling blankets, and
watching for myoglobinuria.

Bacteremia: High-grade fever (greater than 40 C) occurring 30 to 40 minutes after the

beginning of the procedure (e.g., Urinary tract instrumentation in the presence of infected
urine). Management includes blood cultures three times and starting empiric antibiotics.

Gas gangrene of the wound: High-grade fever (greater than 40 C) occurring after
gastrointestinal (GI) surgery due to contamination with Clostridium perfringens; severe
wound pain; treat with surgical debridement and antibiotics.

Febrile non-hemolytic transfusion reaction: Fevers, chills, and malaise 1 to 6 hours after
surgery (without hemolysis). Management: Stop transfusion (rule out hemolytic
transfusion reaction) and give antipyretics (avoid aspirin in the thrombocytopenic patient).

Acute Fever

Fever occurs in the first week (1 to 7 POD).

POD 1 to 3: Pyretic response to surgery occurs during the first 48 hours.[5] Diagnostic
testing is usually not indicated unless there are associated symptoms. After this time
period complete blood count, chest radiograph, urinalysis with culture, blood cultures, and
wound cultures are required as first tests in all patients.

POD 3: Unresolved atelectasis resulting in pneumonia (respiratory symptoms, Chest x-ray

with infiltrates or consolidation, sputum culture, empiric antibiotics and modification
according to culture result and sensitivity), or development of urinary tract infection (urine
analysis and culture, treat with empiric antibiotics and modify according to culture result
and sensitivity)

POD 5: Thrombophlebitis (may be asymptomatic or symptomatic, diagnose with Doppler

ultrasound of deep leg and pelvic veins and treat with heparin)

POD 7: Pulmonary embolism (tachycardia, tachypnea, pleuritic chest pain, ECG with right
heart strain pattern (a low central venous pressure goes against diagnosis), arterial blood
gas with hypoxemia and hypocapnia, confirm the diagnosis with CT angiogram, and treat
with heparin if recurrent pulmonary embolism while anticoagulated with therapeutic INR,
Inferior vena cava filter placement is the next step

POD 7 (5 to 10): Wound infection: Risk increases if the patient is immunocompromised

(e.g., diabetic), abdominal wound, duration of surgery greater than 2 hours, or
contamination during surgery. Signs include erythema, warmth, tenderness, discharge.
Rule out abscess by physical exam plus ultrasound if needed. If an abscess is present,
drainage and antibiotics are needed. Prevention is by careful surgical technique and
prophylactic antibiotics (e.g., intravenous cefazolin at the time of induction of anesthesia
as well as postoperatively if needed)

Subacute Fever

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Fever occurs between postoperative weeks 1 and 4.

POD 10: Deep infection (pelvic or abdominal abscess and if abdominal abscess could be
sub-hepatic or sub-phrenic). A digital rectal exam to rule out the pelvic abscess and CT
scan to localize intra-abdominal abscess. Treatment includes re-exploration vs.
radiological guided percutaneous drainage.

Drugs: Diagnosis of exclusion includes rash and peripheral eosinophilia

Delayed Fever

Fever after more than 4 weeks.

Skin and soft tissue infections (SSTI)

Viral infections

The above differential diagnosis is for causes that are categorized based on timing. However,
there are many other causes that may have specific signs on physical exam and occur after
specific surgery that are not included in the above differential.

Evaluation
Initial assessment includes general appearance, GCS, and vital signs to determine how sick the
patient is.[6][7]

Airway, Breathing, Circulatory, Disability, Exposure (quick assessment to identify and

simultaneously provide appropriate management)

Check patient notes (the type of procedure, timing of the procedure, intraoperative
complications, anesthesia records, patient comorbidities, last ward rounds)

Check patient Intake and Output (including the type of stools, if the patient with type 7
stools rule out Clostridium difficile enterocolitis)

Check patient orders (is the patient being treated with antibiotics or not, receiving deep
vein thrombosis prophylaxis or not)

System based assessment (pulmonary, cardiac, gastrointestinal, urinary)

Sites of infection that are visible (i.e., skin for bedsores, cellulitis, vascular access sites)

Besides tests, vital signs should be monitored. If the patient is hypotensive, venous blood
gas is needed to measure serum lactate. It will guide fluid resuscitation; if the patient is
tachycardic, bedside ECG might be important to confirm their rhythm, might rule out
myocardial infarction; oxygen saturation 96% to 98% in patients with healthy lungs or
89% to 92% in carbon dioxide retaining patients, for example, COPD patients; monitor
blood glucose levels because high blood glucose levels point towards septic response;
urinalysis to rule out urinary tract infection

Blood tests: WBC, CRP especially if trending upward might point towards a septic
response, hemoglobin level would point toward the oxygen-carrying capacity of the blood,
liver function tests to rule out liver injury, coagulation parameters, and platelets to rule out
disseminated intravascular coagulation, renal function to rule out kidney injury or

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electrolyte abnormalities

Microbiology: Cultures (blood, urine, wound, and sputum if producing it), if suspecting
line sepsis (blood culture from the line, remove the line and send the tip to the lab)

Imaging: Chest x-ray (prove or rule out pneumonic process), abdominal imaging
(ultrasound, CT scan to rule out collections)

Venous doppler of the legs to rule out deep vein thrombosis

Treatment / Management
Treatment can include oxygen, fluid balance, intravenous fluids, and a urinary catheter, or
antibiotics.

Drugs: antibiotics, analgesia, antiemetics

Incentive Spirometry

Venous thromboembolism prophylaxis (low molecular weight heparin and wearing

pneumatic stocking)

Escalation (relay information to a senior health professional and ask for further advice
from infectious disease physician)

Differential Diagnosis
As discussed earlier, the differentials are based on the timing of the fever, among other factors.
Some of the important differentials are listed below.

Pneumonia

Pulmonary embolus

Wound infection

Urinary tract infection

Transfusion reaction

Sinusitis

Prognosis
In most patients, postoperative fever is due to a benign cause and resolves spontaneously.
Patients with deep vein thrombosis and pulmonary embolism usually have a low-grade fever that
resolves within a few days of treatment. The prognosis is worse for patients who have
anastomotic leaks or bowel obstruction.

Complications
Failure to diagnose the cause of fever or identify the severity of it can lead the patient into SIRS,
sepsis, severe sepsis, or septic shock. This can lead to prolonged hospitalization and even
increase the mortality rate.

Consultations

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Physician

Infectious disease

Deterrence and Patient Education

Patients who undergo general anesthesia should be advised to use incentive spirometry to prevent
atelectasis. Early mobilization should also be encouraged in postoperative patients where
allowed.

Enhancing Healthcare Team Outcomes

Postoperative fever is a common occurrence on all surgical floors. Because there are so many
causes of fever, the problem is usually managed by an interprofessional team of healthcare
professionals. The nurse is probably the first person who monitors the patient and discovers the
fever. In order to know the cause, the nurse should first check the wound site, auscultate the
lungs, and assess for deep vein thrombosis. Other causes of postoperative fever may be a urinary
tract infection, an intravenous line (thrombophlebitis), or sepsis. Once the fever has been noted,
the health care provider should be notified, and the workup depends on patient presentation and
the day of the fever. If pneumonia is suspected, a chest x-ray may be ordered, blood and urine
culture for sepsis, and a urinary tract infection and duplex ultrasound if a deep vein thrombus is
suspected. The key is to examine the patient as it may provide a clue to the cause. [8][9] [Level
5]

Review Questions

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References
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