A 48-year-old woman comes to the hospital for elective cholecystectomy to treat symptomatic cholelithiasis. She has had increasingly severe, intermittent biliary colic pain, and ultrasonography revealed several gallstones. The patient has a history of hypertension and obesity. Preoperative medical evaluation and laboratory testing were unremarkable. The patient receives cefazolin for surgical site infection prophylaxis, and surgery is performed under general anesthesia. A Foley catheter is placed preoperatively. The planned laparoscopic procedure is converted to open approach due to difficult anatomy; otherwise, the surgery is uneventful with minimal blood loss. Two hours later, the patient is noted to have a temperature of 38.9 C (102 F). Her blood pressure is 140/85 mm Hg, pulse is 104/min, and respirations are 18/min. The patient is awake and alert but reports mild pain at the surgical site. A right-sided internal jugular central venous catheter, which was placed in the operating room, is in a good position with no redness at the insertion site. The lungs are clear on auscultation, and heart sounds are normal. The surgical site is clean with minimal serosanguinous discharge. There is no lower extremity edema. Current laboratory results are as follows: Chest x-ray reveals decreased lung volumes and small areas of subsegmental thickening bilaterally. Which of the following is the most appropriate next step in management of this patient's fever?

Question

A 48-year-old woman comes to the hospital for elective cholecystectomy to treat symptomatic cholelithiasis.  She has had increasingly severe, intermittent biliary colic pain, and ultrasonography revealed several gallstones.  The patient has a history of hypertension and obesity.  Preoperative medical evaluation and laboratory testing were unremarkable.  The patient receives cefazolin for surgical site infection prophylaxis, and surgery is performed under general anesthesia.  A Foley catheter is placed preoperatively.  The planned laparoscopic procedure is converted to open approach due to difficult anatomy; otherwise, the surgery is uneventful with minimal blood loss.  Two hours later, the patient is noted to have a temperature of 38.9 C (102 F).  Her blood pressure is 140/85 mm Hg, pulse is 104/min, and respirations are 18/min.  The patient is awake and alert but reports mild pain at the surgical site.  A right-sided internal jugular central venous catheter, which was placed in the operating room, is in a good position with no redness at the insertion site.  The lungs are clear on auscultation, and heart sounds are normal.  The surgical site is clean with minimal serosanguinous discharge.  There is no lower extremity edema.  Current laboratory results are as follows:  Chest x-ray reveals decreased lung volumes and small areas of subsegmental thickening bilaterally.  Which of the following is the most appropriate next step in management of this patient's fever?

Quizplus · Accepted Answer

11ec25c8_d921_ca72_bc81_17168e574aaa_MD0003_00 Postoperative fever, defined as temperature >38 C (100.4 F), is common following major surgery and is generally mediated by the release of pyretic cytokines (eg, IL-1, IL-6, TNF-α, IFN-γ) in response to tissue trauma, blood cell lysis, or bacterial endotoxins/exotoxins. The underlying etiology can often be differentiated based on how much time has elapsed since surgery. Immediate postoperative fever occurs within hours of the operation. Most cases are caused by tissue damage incurred during a major procedure (eg, open cholecystectomy); fever and leukocytosis generally last <3 days and are managed symptomatically (eg, acetaminophen) and observed. Other causes of immediate fever include blood transfusion and drug reactions; these are often associated with hypotension (due to vasodilation) and rash. Acute (1-7 days postoperatively) and subacute (7-28 days postoperatively) fever is usually caused by bacterial infection. Fever is delayed with infection because several days of bacterial replication are generally necessary to produce enough endotoxin/exotoxin to generate fever. Most acute postoperative fevers are caused by nosocomial infections such as urinary tract infection and pneumonia (Choice D), whereas subacute postoperative fevers are often due to abscess or infection of a central line or surgical site (Choices A and C). (Choice B) Postoperative atelectasis is not generally considered an independent cause of fever but can predispose patients to developing pneumonia. Atelectasis is usually managed/prevented with incentive spirometry, not positive airway pressure and chest physiotherapy (these measures are primarily reserved for those with excessive secretions that lead to respiratory plugging). (Choice E) Malignant hyperthermia is a rare cause of immediate postoperative fever. It is triggered by exposure to volatile anesthetics/succinylcholine and generally presents intraoperatively with severe muscle rigidity, hypercarbia, tachypnea, and tachycardia. Urgent treatment with dantrolene (a skeletal muscle relaxant) and cooling measures is required to prevent death. Educational objective: Postoperative fever is generally mediated by cytokine release in response to tissue trauma, blood cell lysis, or infection. Immediate postsurgical fever occurs within hours of the operation and is usually due to tissue trauma, mismatched blood products, or drug reactions. Acute (1-7 days postoperatively) and subacute (7-28 days postoperatively) fever is generally driven by infections.

A 48-Year-Old Woman Comes to the Hospital for Elective Cholecystectomy