What is the management of post-operative fever on day zero?

From the Guidelines

Management of post-operative fever on day zero involves a systematic approach focusing on common causes while maintaining vigilance for serious complications. Initial management should include a thorough assessment of vital signs, physical examination, and review of the surgical procedure. According to the guidelines for evaluation of new fever in critically ill adult patients 1, fever in the early postoperative period is usually non-infectious in origin, and considerable money can be wasted in overzealous evaluation of early postoperative fever. The first-line antipyretic should be acetaminophen (650-1000mg every 6 hours), with NSAIDs like ketorolfen (15-30mg IV) as alternatives if not contraindicated. Ensure adequate hydration with IV fluids if the patient cannot tolerate oral intake. Basic diagnostic workup should include complete blood count, urinalysis, chest X-ray, and blood cultures if the fever exceeds 38.5°C (101.3°F) or if the patient appears septic. Most immediate post-operative fevers are due to the normal inflammatory response to surgical trauma with cytokine release, atelectasis, or medication reactions rather than infection. Atelectasis should be addressed with incentive spirometry, early ambulation, and deep breathing exercises. While monitoring the patient, remember that fever within the first 24 hours rarely indicates surgical site infection and typically resolves spontaneously. However, persistent fever, hypotension, tachycardia, or altered mental status warrants more aggressive investigation and management for potential serious complications like pulmonary embolism, aspiration pneumonia, or early-onset sepsis. Some key points to consider in the management of post-operative fever include:

• The use of antimicrobial therapy is an adjuvant treatment and must be combined with early surgical debridement, as recommended by the 2018 WSES/SIS-E consensus conference 1.
• The most important therapy for a surgical site infection is to open the incision, evacuate the infected material, and continue dressing changes until the wound heals by secondary intention, as stated in the practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America 1.
• Recognition of higher-risk patients is the key to achieving the desired response, as potent broad-spectrum therapy is probably needed, according to the review of the guidelines for complicated skin and soft tissue infections and intra-abdominal infections 1. The management of post-operative fever on day zero should prioritize a thorough assessment, adequate hydration, and monitoring for potential complications, with a focus on the most likely causes and adjusting treatment accordingly.

From the FDA Drug Label

The prophylactic administration of Cefazolin for Injection, USP preoperatively, intraoperatively, and postoperatively may reduce the incidence of certain postoperative infections in patients undergoing surgical procedures which are classified as contaminated or potentially contaminated The prophylactic administration of Cefazolin for Injection, USP should usually be discontinued within a 24-hour period after the surgical procedure. If there are signs of infection, specimens for cultures should be obtained for the identification of the causative organism so that appropriate therapy may be instituted.

The management of post-operative fever on day zero may involve the use of antibiotics such as Cefazolin 2. The decision to continue or discontinue prophylactic antibiotic administration should be based on the presence of signs of infection and the results of culture and susceptibility testing.

• Key considerations:
  • Discontinue prophylactic antibiotics within 24 hours after surgery, unless there are signs of infection.
  • Obtain specimens for culture and susceptibility testing if signs of infection are present.
  • Adjust antibiotic therapy based on culture and susceptibility results.

From the Research

Management of Post-Operative Fever on Day Zero

The management of post-operative fever on day zero involves a systematic approach to differentiate between a normal physiologic response to surgery and a pathologic cause.

• Most fevers that develop within the first 48 hours after surgery are benign and self-limiting 3.
• A helpful mnemonic to evaluate postoperative fever is the "four Ws": wind (pulmonary causes), water (urinary tract infection), wound (surgical site infection), and "what did we do?" (iatrogenic causes) 3.
• Elevated body temperature of > 99.9°F or 37.7 °C for over 48 h or associated with clinical deterioration or localising features should be considered as "fever" and evaluated according to a standard protocol 4.
• Transient elevation of temperature, occurring in the first 48 h after surgery, is most common and usually does not require extensive evaluation 4, 5.
• A brief bedside evaluation has the highest yield for determining the fever etiology, and extensive evaluations with cultures and chest imaging have little to no benefit in patients admitted for elective surgery 5.

Causes of Post-Operative Fever

• The most common causes of fever are urinary tract infections, followed by aseptic meningitis, wound infections, and pneumonia 4.
• Various aetiologies of fever follow distinct patterns, with COVID-19 and meningitis causing high-grade, prolonged fever 4.
• Cranial surgery, prolonged duration of surgery, urinary catheters, and wound drains retained beyond post-operative day 3 are predictors of fever 4.

Evaluation and Treatment

• A systematic approach to febrile postoperative patients can help clinicians make better use of resources, limit costly workups, and improve patient outcomes 6.
• Advanced practice registered nurses (APRNs) should approach each instance of postoperative fever in a systematic manner, taking into account a variety of factors, such as patient's medical history, physical examination findings, and type of surgery 7.
• By being aware of the causes of postoperative fever, APRNs can also take prophylactic action to decrease the risk associated with many of these potential febrile causes 7.