A 55-year-old man undergoes a conventional pancreaticoduodenectomy (Whipple procedure) for suspected pancreatic adenocarcinoma of the head of the pancreas. Prior to the procedure, the patient receives a dose of prophylactic antibiotics. Toward the end of the operation, he is given 2 units of packed red blood cells. The patient is then extubated and transferred to the postanesthesia care unit for recovery. One hour later, he develops fever and chills. Temperature is 38.5 C (101.3 F), blood pressure is 130/76 mm Hg, pulse is 90/min, and respirations are 16/min. The patient is mildly sedated but responds to commands appropriately. Examination shows a mildly tender abdominal wound without erythema. There is serosanguinous discharge from the pancreatic suction drain. The lungs are clear to auscultation. A Foley catheter and right subclavian central venous access are present, both placed at the time of surgery. Which of the following is the most likely cause of this patient's fever?

Question

A 55-year-old man undergoes a conventional pancreaticoduodenectomy (Whipple procedure) for suspected pancreatic adenocarcinoma of the head of the pancreas.  Prior to the procedure, the patient receives a dose of prophylactic antibiotics.  Toward the end of the operation, he is given 2 units of packed red blood cells.  The patient is then extubated and transferred to the postanesthesia care unit for recovery.  One hour later, he develops fever and chills.  Temperature is 38.5 C (101.3 F), blood pressure is 130/76 mm Hg, pulse is 90/min, and respirations are 16/min.  The patient is mildly sedated but responds to commands appropriately.  Examination shows a mildly tender abdominal wound without erythema.  There is serosanguinous discharge from the pancreatic suction drain.  The lungs are clear to auscultation.  A Foley catheter and right subclavian central venous access are present, both placed at the time of surgery.  Which of the following is the most likely cause of this patient's fever?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d921_2e30_bc81_b70d8003eec7_MD0003_00 Postoperative fever (>38 C [100.4 F]) is common after major surgery and can be due to infectious or noninfectious causes. The timing of the fever helps guide the diagnosis. Fever occurring immediately (within a few hours) in the operative or postoperative period is typically associated with the following: Prior infection or trauma Inflammation due to surgery Malignant hyperthermia Anesthetic medications Blood products This patient developed fever within hours of receiving blood products; therefore, the most likely cause is a febrile nonhemolytic transfusion reaction. During blood storage, leukocytes release cytokines that when transfused can cause transient fevers, chills, and malaise (without hemolysis) within 1-6 hours of transfusion. Management includes transfusion cessation (to rule out other serious causes of fever) and antipyretics. (Choices A and D) Acute fever (within the first week after surgery) is often caused by nosocomial infections (eg, pneumonia, urinary tract infection) or noninfectious etiologies such as pulmonary embolus (PE). The risk of infection due to indwelling urinary and central venous catheters increases with the duration of catheterization and does not typically occur in the immediate postoperative period. PE may occur within days to weeks after surgery but usually presents in conjunction with pleuritic chest pain, tachycardia, and/or respiratory distress (eg, tachypnea, hypoxia). (Choices B and E) Subacute fever (>1 week after surgery) is typically due to drug fever or surgical site infection. Drug fever from antibiotics (commonly beta-lactams) is a diagnosis of exclusion and is often accompanied by rash and peripheral eosinophilia. Although a minority of surgical site infections can cause fever in the immediate postoperative period (eg, group A Streptococcus), these are fulminant infections causing pain, erythema, and edema. This patient's mildly tender wound without erythema is normal. (Choice C) Malignant hyperthermia (usually caused by inhaled anesthetics) presents with high fever (>40 C [104 F]), muscle rigidity, and hemodynamic instability in the immediate intra- or postoperative period. This patient has normal vital signs and no muscle rigidity, making this diagnosis unlikely. Educational objective: Febrile nonhemolytic transfusion reactions occur within 1-6 hours of transfusion initiation and can present in the immediate (within a few hours) postoperative period in patients who receive blood products intraoperatively. Other causes of immediate postoperative fever include prior infection or trauma, inflammation due to surgery, malignant hyperthermia, and anesthetic medications. References: Postoperative fever. (http://www.ncbi.nlm.nih.gov/pubmed/29493924)

A 55-Year-Old Man Undergoes a Conventional Pancreaticoduodenectomy (Whipple Procedure) for Suspected