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Fever in the postoperative period∗
Fever in the Postoperative ROBERT I. WISE, Philadelphia,
M.D.,
Period*
PH.D.
Pennsylvania
infection of the wound, the urinary tract, pneumonia as a result of aspiration during the period of anesthesia, pulmonary infarction, atelectasis due to bronchial obstruction, myocardial infarction, thrombophlebitis, dehydration, necrotic sterile tissue left within the wound, pyrogenic reactions resulting from infused solutions or blood, hypersensitivity reactions to drugs, blood transfusion or other agents, bacterial enterocolitis, bacteremia, tuberculosis, hyperthyroidism or other causes of fever. It is good practice to obtain past history and a complete description of complaints from the patient. The physical examination must be thorough and repeated often. The wound must be examined carefully for it may be difficult to evaluate since the signs of inflammation, redness, heat, tenderness and swelling are present during the primary stage of healing. If there is fluctuation, crepitation or presence of fluid, material from the wound may reveal the presence of the etiologic agent in microscopic examinations and appropriate bacteriologic culture. It is not difficult to recognize thepresence of neutrophilic cells and gram-positive cocci in clusters indicating Staphylococcus, or gram positive cocci in chains indicating Streptococcus, or gramnegative bacilli which may be any genus such as Escherichia, Aerobacter, Psedomonas, Proteus, and the like. A gram-positive bacillus with swollen spores indicates a clostridial infection with subsequent evidence of gas gangrene. The recognition of morphologic groups or types of bacteria aids in choice of antibiotics and eliminates certain types of bacteria as the cause. This procedure allows selection and prompt institution of appropriate therapy and avoids the wasteful use of antibiotics which would have little or no effect. Minimal laboratory studies may be considered for the problem patient. These should include a white blood count and differential count. In addition, it may be helpful to examine the
F
EVER in a postoperative patient is a dreaded complication because it portends a course which may vary from a mild benign episode to a fatal result. The patient is subject to the further expenses of diagnostic tests, a prolonged hospitalization, additional surgical procedures and expensive therapeutic agents, and subject to delayed healing of the wound, the possibility of advancing infection, bacteremia and metaThere is anxiety on the part of static abscesses. everyone associated with the welfare of the patient. The cause of fever in the postoperative period must be determined as rapidly as possible so that appropriate therapeutic measures can be It is imperative that reasonable instituted. steps be taken to obtain the correct diagnosis before empirical antibiotic or chemotherapeutic agents are administered. If inadequate or inappropriate therapy is instituted without knowledge of the cause, the infection, if present, may advance unhindered. An inadequate antibiotic may not cure but may keep the infection quiescent only to recur when therapy The inappropriate antibiotic is discontinued. may have sufficient effect to prevent bacteriologic diagnosis because of its bacteriostatic concentration in the specimen and have insufficient effect to cure the infection. The utilization of inadequate or inappropriate therapy may lull the physician into a false sense of security and prejudice him from careful observation and search for clues to the true cause of the fever. This does not mean that there is no need for empiricism in the selection of therapy in the absence of knowledge of the infecting agent. There is often the necessity for choosing antibacterial therapy before a diagnosis is made, but only after extensive study and the collection of appropriate specimens for bacteriologic examination should antibacterial therapy be instituted. The causes of fever are varied. There may be
* From the Department of Medicine, Jefferson Medical Co&ye, Philadelphia, Pa. 0 CTOBER
1963
475
476 urinary sediment for pyuria and bacteriuria and to examine a roentgenogram of the chest. If there are signs of pulmonary complications, the sputum should be collected and examined immediately for the presence of blood which may indicate pulmonary infarction. By observation of a gram stain of the sputum, it is possible to detect neutrophils which indicate infection and to observe the morphologic type of bacteria causing pneumonia. The type of bacteria seen will indicate the appropriate antibiotic agents, and selection can be accomplished the day before the bacteriologic culture is observable. A roentgenogram of the chest aids in diagnosis since it may help differentiate pneumonia, pulmonary infarction and atelectasis. Bacteriologic studies of the urine, blood, drainage from the wound or other appropriate specimens may reveal the site and type of infection. In patients who develop fever with evidence of peripheral vascular collapse and diarrhea, the only specific diagnostic test that establishes the diagnosis of staphylococcal enterocolitis is a gram stain of the feces and the observation of large numbers of gram-positive cocci in clusters, for the normal stool contains sufficient staphylococci to confuse the interpretation of bacteriologic culture. A definite advantage of the gram stain is the hours gained in establishing therapy the day before cultures are comIf the enterocolitis is caused by pleted. Pseudomonas, the diagnosis cannot be made by gram stain since gram-negative rods are normally present in large numbers in feces and cannot be differentiated into specific genera as is possible with the cocci. If fever follows blood transfusion, the possibility of mismatching should immediately be checked and a bacteriologic study made to determine the presence of bacteria. Thrombophlebitis is a frequent postoperative complication and can be determined by careful appropriate physical examination of the extremities, particularly if there has been intraIf there is evidence of invenous therapy.
flammation at the site of indwelling venous catheters or needles, intravenous administration of fluid or medications should be discontinued or a new site selected if therapy is to be continued. Infection of the surgical wound may be caused by a variety of bacteria. Staphylococcus aureus is the most common. Gram-negative rods such as Pseudomonas, coliform bacilli and Streptococcus can play roles in the infection. The incidence of infections of the surgical wound varies from hospital to hospital, and the accuracy of reports is dependent on the interest and diligence of the medical staff. It can be as high as 10 per cent without the medical staff being impressed with a problem. With diligence and effort, the rate is reduced to less than 2 per cent. SUMMARY
The occurrence of fever in the postoperative patient portends a course which may vary from a mild benign episode to a fatal result. The causes are varied and are both noninfectious and infectious. Antibacterial therapy must be used only after thorough evaluation to determine the probable etiology of fever. If there are signs of infection, the microscopic examination of gramstained material of appropriate specimens allows recognition of morphologic groups of bacteria. Then the physician can eliminate certain causes and include other possible causes of infection and fever. This allows selection of appropriate antibacterial therapy, one to three days before reports of cultures and tests for antibiotic susceptibility are received. BIBLIOGRAPHY 1.
MELENEY,F.
L.
Infection in clean operative wounds, a nine-year study. Sur,. Gynec. & Obst., 60: 264, 1935. 2. CUTLER, E. C. and HUNT, A. M. Postoperative pulmonary complications. Arch. Znt. Med., 29:
449,1922. 3. HOWE, C. W.
Postoperative to Staphylococcus aureus.
wound infections due New England J. Med.,
251: 441,1954. 4. PULASKI, E. J.
Surgical Infections: Prophylaxis, Treatment, Antibiotic Therapy. Springfield, Ill., 1954. Charles C Thomas.
THE AMERICAN JOURNAL OF CARDIOLOGY
M.D.,
Period*
PH.D.
Pennsylvania
infection of the wound, the urinary tract, pneumonia as a result of aspiration during the period of anesthesia, pulmonary infarction, atelectasis due to bronchial obstruction, myocardial infarction, thrombophlebitis, dehydration, necrotic sterile tissue left within the wound, pyrogenic reactions resulting from infused solutions or blood, hypersensitivity reactions to drugs, blood transfusion or other agents, bacterial enterocolitis, bacteremia, tuberculosis, hyperthyroidism or other causes of fever. It is good practice to obtain past history and a complete description of complaints from the patient. The physical examination must be thorough and repeated often. The wound must be examined carefully for it may be difficult to evaluate since the signs of inflammation, redness, heat, tenderness and swelling are present during the primary stage of healing. If there is fluctuation, crepitation or presence of fluid, material from the wound may reveal the presence of the etiologic agent in microscopic examinations and appropriate bacteriologic culture. It is not difficult to recognize thepresence of neutrophilic cells and gram-positive cocci in clusters indicating Staphylococcus, or gram positive cocci in chains indicating Streptococcus, or gramnegative bacilli which may be any genus such as Escherichia, Aerobacter, Psedomonas, Proteus, and the like. A gram-positive bacillus with swollen spores indicates a clostridial infection with subsequent evidence of gas gangrene. The recognition of morphologic groups or types of bacteria aids in choice of antibiotics and eliminates certain types of bacteria as the cause. This procedure allows selection and prompt institution of appropriate therapy and avoids the wasteful use of antibiotics which would have little or no effect. Minimal laboratory studies may be considered for the problem patient. These should include a white blood count and differential count. In addition, it may be helpful to examine the
F
EVER in a postoperative patient is a dreaded complication because it portends a course which may vary from a mild benign episode to a fatal result. The patient is subject to the further expenses of diagnostic tests, a prolonged hospitalization, additional surgical procedures and expensive therapeutic agents, and subject to delayed healing of the wound, the possibility of advancing infection, bacteremia and metaThere is anxiety on the part of static abscesses. everyone associated with the welfare of the patient. The cause of fever in the postoperative period must be determined as rapidly as possible so that appropriate therapeutic measures can be It is imperative that reasonable instituted. steps be taken to obtain the correct diagnosis before empirical antibiotic or chemotherapeutic agents are administered. If inadequate or inappropriate therapy is instituted without knowledge of the cause, the infection, if present, may advance unhindered. An inadequate antibiotic may not cure but may keep the infection quiescent only to recur when therapy The inappropriate antibiotic is discontinued. may have sufficient effect to prevent bacteriologic diagnosis because of its bacteriostatic concentration in the specimen and have insufficient effect to cure the infection. The utilization of inadequate or inappropriate therapy may lull the physician into a false sense of security and prejudice him from careful observation and search for clues to the true cause of the fever. This does not mean that there is no need for empiricism in the selection of therapy in the absence of knowledge of the infecting agent. There is often the necessity for choosing antibacterial therapy before a diagnosis is made, but only after extensive study and the collection of appropriate specimens for bacteriologic examination should antibacterial therapy be instituted. The causes of fever are varied. There may be
* From the Department of Medicine, Jefferson Medical Co&ye, Philadelphia, Pa. 0 CTOBER
1963
475
476 urinary sediment for pyuria and bacteriuria and to examine a roentgenogram of the chest. If there are signs of pulmonary complications, the sputum should be collected and examined immediately for the presence of blood which may indicate pulmonary infarction. By observation of a gram stain of the sputum, it is possible to detect neutrophils which indicate infection and to observe the morphologic type of bacteria causing pneumonia. The type of bacteria seen will indicate the appropriate antibiotic agents, and selection can be accomplished the day before the bacteriologic culture is observable. A roentgenogram of the chest aids in diagnosis since it may help differentiate pneumonia, pulmonary infarction and atelectasis. Bacteriologic studies of the urine, blood, drainage from the wound or other appropriate specimens may reveal the site and type of infection. In patients who develop fever with evidence of peripheral vascular collapse and diarrhea, the only specific diagnostic test that establishes the diagnosis of staphylococcal enterocolitis is a gram stain of the feces and the observation of large numbers of gram-positive cocci in clusters, for the normal stool contains sufficient staphylococci to confuse the interpretation of bacteriologic culture. A definite advantage of the gram stain is the hours gained in establishing therapy the day before cultures are comIf the enterocolitis is caused by pleted. Pseudomonas, the diagnosis cannot be made by gram stain since gram-negative rods are normally present in large numbers in feces and cannot be differentiated into specific genera as is possible with the cocci. If fever follows blood transfusion, the possibility of mismatching should immediately be checked and a bacteriologic study made to determine the presence of bacteria. Thrombophlebitis is a frequent postoperative complication and can be determined by careful appropriate physical examination of the extremities, particularly if there has been intraIf there is evidence of invenous therapy.
flammation at the site of indwelling venous catheters or needles, intravenous administration of fluid or medications should be discontinued or a new site selected if therapy is to be continued. Infection of the surgical wound may be caused by a variety of bacteria. Staphylococcus aureus is the most common. Gram-negative rods such as Pseudomonas, coliform bacilli and Streptococcus can play roles in the infection. The incidence of infections of the surgical wound varies from hospital to hospital, and the accuracy of reports is dependent on the interest and diligence of the medical staff. It can be as high as 10 per cent without the medical staff being impressed with a problem. With diligence and effort, the rate is reduced to less than 2 per cent. SUMMARY
The occurrence of fever in the postoperative patient portends a course which may vary from a mild benign episode to a fatal result. The causes are varied and are both noninfectious and infectious. Antibacterial therapy must be used only after thorough evaluation to determine the probable etiology of fever. If there are signs of infection, the microscopic examination of gramstained material of appropriate specimens allows recognition of morphologic groups of bacteria. Then the physician can eliminate certain causes and include other possible causes of infection and fever. This allows selection of appropriate antibacterial therapy, one to three days before reports of cultures and tests for antibiotic susceptibility are received. BIBLIOGRAPHY 1.
MELENEY,F.
L.
Infection in clean operative wounds, a nine-year study. Sur,. Gynec. & Obst., 60: 264, 1935. 2. CUTLER, E. C. and HUNT, A. M. Postoperative pulmonary complications. Arch. Znt. Med., 29:
449,1922. 3. HOWE, C. W.
Postoperative to Staphylococcus aureus.
wound infections due New England J. Med.,
251: 441,1954. 4. PULASKI, E. J.
Surgical Infections: Prophylaxis, Treatment, Antibiotic Therapy. Springfield, Ill., 1954. Charles C Thomas.
THE AMERICAN JOURNAL OF CARDIOLOGY