How to manage fever on post-operative day 2 after laparotomy with omental patch repair for peptic perforation?

Management of Fever on Post-Operative Day 2 After Laparotomy with Omental Patch Repair for Peptic Perforation

In a patient with fever on post-operative day 2 after laparotomy with omental patch repair for peptic perforation, initiate empiric antibiotic therapy targeting common intra-abdominal pathogens while obtaining blood and urine cultures, and evaluate for potential complications including anastomotic leak, intra-abdominal abscess, or surgical site infection.

Initial Assessment

Clinical Evaluation

• Assess vital signs: temperature pattern, heart rate, blood pressure, respiratory rate
• Evaluate for signs of sepsis: tachycardia, hypotension, tachypnea
• Examine the surgical wound for signs of infection: erythema, purulent discharge, dehiscence
• Perform abdominal examination: tenderness, distension, guarding, rigidity

Laboratory Investigations

• Complete blood count with differential (leukocytosis with left shift suggests infection)
• Blood cultures (at least two sets from different sites) 1
• Urinalysis and urine culture 1
• C-reactive protein and procalcitonin (if available)
• Renal and liver function tests

Antibiotic Management

For Immunocompetent, Non-Critically Ill Patients

• Initiate empiric antibiotic therapy with amoxicillin/clavulanate 2 g/0.2 g q8h 2
• For patients with documented beta-lactam allergy: eravacycline 1 mg/kg q12h or tigecycline 100 mg loading dose then 50 mg q12h 2

For Immunocompromised or Critically Ill Patients

• Piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g q6h or 16 g/2 g by continuous infusion 2
• For patients with documented beta-lactam allergy: eravacycline 1 mg/kg q12h 2

For Septic Shock

• Meropenem 1 g q6h by extended infusion or continuous infusion, OR
• Doripenem 500 mg q8h by extended infusion or continuous infusion, OR
• Imipenem/cilastatin 500 mg q6h by extended infusion, OR
• Eravacycline 1 mg/kg q12h 2

Duration of Therapy

• 4 days for immunocompetent, non-critically ill patients if source control is adequate 2
• Up to 7 days for immunocompromised or critically ill patients based on clinical condition and inflammatory markers 2
• Patients with ongoing signs of infection beyond 7 days warrant diagnostic investigation 2

Imaging Studies

When to Obtain Imaging

• Persistent fever despite appropriate antibiotic therapy
• Worsening abdominal pain or distension
• Development of peritoneal signs
• Hemodynamic instability or sepsis

Recommended Imaging

• CT scan with IV contrast is the preferred modality to evaluate for:
  • Intra-abdominal abscess
  • Anastomotic leak
  • Signs of peritonitis
  • Extraluminal gas or fluid collections 2

Management of Specific Complications

Intra-abdominal Abscess

• Localized abscess: percutaneous drainage if accessible 2
• Continue appropriate antibiotic therapy

Anastomotic Leak or Patch Failure

• Immediate surgical exploration for unstable patients with peritonitis 2
• Consider laparoscopic approach in stable patients 2
• Primary repair with omental patch for small defects (<1 cm) 2
• Consider damage control surgery and open abdomen in hemodynamically unstable patients 2

Surgical Site Infection

• Open and drain the wound
• Send wound cultures
• Daily wound care and dressing changes

Monitoring and Follow-up

• Monitor vital signs frequently to assess for worsening infection or development of sepsis 1
• Follow clinical response to antibiotics (temperature trends, white blood cell count) 1
• Suspect perforation or leak if patient develops persistent pain, breathlessness, fever, or tachycardia 2

Important Considerations

• Fever appearing after 48 hours postoperatively has a higher probability of representing an infection, while fever in the first 48 hours may be related to the normal inflammatory response to surgery 1
• Routine use of intra-abdominal surgical drains is discouraged given lack of evidence of benefit in clean and clean/contaminated cases 2
• A prospective case-control study found that closure of peptic perforation with omental patch technique was safe without prophylactic intra-abdominal drainage 2
• Drain-related morbidity (fever, wound infections, peritoneal fluid accumulation, and wound dehiscence) suggests that drains should be avoided where possible 2

Pitfalls to Avoid

• Delaying surgical re-exploration in patients with signs of peritonitis or septic shock
• Attributing early postoperative fever to atelectasis without excluding infectious causes
• Inadequate antibiotic coverage for potential pathogens
• Prolonged antibiotic therapy without clear indication
• Failure to adjust antibiotics based on culture results

By following this systematic approach to fever management after peptic ulcer repair, complications can be identified early and treated appropriately, reducing morbidity and mortality.