What are the implications of fever in an incarcerated (irreducible) hernia?

From the Guidelines

Fever in an incarcerated hernia is a sign of strangulation and requires immediate surgical intervention to prevent bowel ischemia, necrosis, and bacterial translocation. If a patient with an incarcerated hernia develops fever, this suggests that the blood supply to the herniated tissue is compromised, leading to tissue death and subsequent infection, which can rapidly progress to peritonitis, sepsis, and multi-organ failure if not addressed promptly 1. The initial management includes:

• Fluid resuscitation with isotonic crystalloids, such as normal saline or lactated Ringer's at 1-2 L bolus
• Nothing by mouth status
• Nasogastric tube placement for decompression
• Broad-spectrum antibiotics, such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours
• Pain management with opioid analgesics like morphine 2-4mg IV every 4 hours as needed
• Laboratory tests, including complete blood count, comprehensive metabolic panel, and blood cultures
• Imaging with CT scan may be performed if the patient is stable, but should not delay surgical consultation

The definitive treatment is emergency surgery to reduce the hernia, assess bowel viability, resect any necrotic tissue, and repair the hernia defect 1. It is crucial to note that mesh use in emergency hernia repair may be associated with an increased risk of surgical site contamination and recurrence, especially in the presence of bowel involvement and potential bacterial translocation 1. Therefore, the decision to use mesh should be made on a case-by-case basis, taking into account the individual patient's risk factors and the surgeon's expertise. Prompt surgical intervention is critical to prevent morbidity, mortality, and to improve the patient's quality of life.

From the Research

Fever in Incarcerated Hernia

• Fever is a common symptom associated with incarcerated hernias, particularly if the hernia becomes strangulated, leading to tissue necrosis and potential infection 2, 3, 4, 5.
• The management of incarcerated hernias often involves emergency surgery, and the presence of fever may indicate the need for prompt intervention to prevent further complications 3, 4, 5.
• Studies have shown that the risk of complications, including infection and necrosis, increases with the duration of incarceration, emphasizing the importance of timely treatment 4, 5.
• While antibiotics may be used to manage infections associated with incarcerated hernias, the choice of antibiotic should be guided by the suspected or confirmed causative organism, and ceftriaxone may not be the optimal choice for methicillin-susceptible Staphylococcus aureus (MSSA) infections 6.

Risk Factors for Complications

• Prolonged incarceration time is a significant risk factor for ischemia and necrosis of hernia contents, which can lead to fever and other complications 4.
• Other risk factors for complications include comorbidities such as diabetes, cardiopathy, and ASA grade 3/4, as well as the need for bowel resection 5.
• The use of mesh in the treatment of incarcerated hernias is a topic of debate, but some studies suggest that it may be safe and effective even in cases with potential infection 5.

Management Options

• Emergency surgery is often necessary to manage incarcerated hernias, and the choice of surgical technique may depend on the presence of complications such as ischemia or necrosis 3, 4, 5.
• The use of antibiotics and other supportive measures may be necessary to manage infections and other complications associated with incarcerated hernias 3, 5, 6.