From the Guidelines
For a postoperative patient with fever after laparoscopic ventral hernia repair, the best course of action is to first evaluate for potential causes of infection while initiating appropriate management, and given the patient's recent surgery, a computed tomography (CT) of the abdomen and pelvis with contrast is usually appropriate to evaluate for postoperative abscesses, leaks, or hemorrhage, as recommended by the most recent guidelines 1. The patient's presentation with fever on the second postoperative day, although not extremely high, warrants a thorough investigation to rule out potential postoperative complications.
- A thorough physical examination focusing on the surgical site, lungs, and urinary system has already been performed, and the patient is alert, oriented, and in no acute distress.
- Laboratory tests including complete blood count and basic metabolic panel are within normal limits, but these may not be sufficient to rule out all potential causes of fever.
- Imaging studies, particularly a CT of the abdomen and pelvis with contrast, are recommended for patients who have recently undergone thoracic, abdominal, or pelvic surgery if an etiology is not readily identified by the initial workup 1.
- While awaiting results, empiric antibiotic therapy may be considered, but the most important step is to identify the cause of the fever to guide targeted treatment.
- The patient's wound drain has 10 mL of serosanguineous fluid, which may not be indicative of a significant infection, but the presence of fever still necessitates further evaluation. Given the recent surgery and the presence of fever, the most appropriate next step is to perform a CT of the abdomen and pelvis with contrast to evaluate for potential postoperative complications, as this aligns with the recommendations from the Society of Critical Care Medicine and the Infectious Diseases Society of America 1.
From the Research
Postoperative Fever Evaluation
The patient presents with a fever on the second postoperative day after laparoscopic ventral hernia repair, which can be caused by various factors, including infection or non-infectious causes.
- The patient's temperature is 38.3 C (100.9 F), and the physical examination reveals mild tenderness around the midline and laparoscopy incision, but no other significant findings.
- Laboratory results, including complete blood count and basic metabolic panel, are within normal limits, and point-of-care glucose checks have been between 120 and 160 mg/dL since admission.
Diagnostic Approach
According to the study by 2, determining the underlying cause of a fever can be a daunting task, and an organized approach is necessary to reach a correct diagnosis. The first step is a complete assessment, including a thorough physical assessment and evaluation of the history of present illness.
- The study by 3 emphasizes the importance of distinguishing between infectious and non-infectious causes of fever and discusses the evaluation of fever, indications for obtaining cultures, and the use of procalcitonin.
- The study by 4 suggests that routine evaluations of fever do not alter the outcome of the majority of patients and are not cost-effective, and that the correct diagnosis can often be made based on clinical findings and confirmed by a single appropriate test.
Recommendations
Based on the patient's presentation and the available evidence, the best course of action would be to:
- Monitor the patient's condition closely and repeat the physical examination and laboratory tests as necessary.
- Consider obtaining cultures, including blood and urine cultures, if the patient's condition worsens or if there is a high suspicion of infection.
- Avoid routine ordering of unnecessary tests, as this can result in excess expenditure and may not alter the patient's outcome.
The most appropriate answer is: C. No additional diagnostic studies at this time, as the patient's condition is stable, and the laboratory results are within normal limits. However, close monitoring and repeated evaluations are necessary to determine the cause of the fever and guide further management, as suggested by 5.