CASE BASED LEARNINGPOSTOPERATIVE FEVER POD# 1=Wind

Dr.B.Selvaraj MS;Mch;FICS;Professor of SurgeryMelaka Manipal Medical CollegeMelaka 75150 Malaysia

CASE BASED LEARNING

66 years old woman underwent hemi-colectomy after a perforation due to diverticulitis.The patient is on postoperative day 1 and complains of cough and is noted to have fever.She was intubated for the procedure with a laryngeal mask airway.Vitals: BP 130/80; HR102; RR19; T 101*O/E: Dull on percussion over LLL area; Breath sounds diminished

CASE BASED LEARNING What is your diagnosis? Fever in postop day 1 to 3 is due to Atelectasis or

Pneumonia Mnemonic: Wind – POD # 1 to 3 Atelectasis & Pneumonia Water – POD # 3 to 5 CA- UTI Walking- POD# 4 to 8 DVT & PE Wound-POD# 5 to 7 SSI Wonder drugs- anytime Drug fever

CXR- ATELECTASIS What is the

best next step?

- CXR- PA and lateral views

- Post-op Atelectasis

CXR- PNEUMONIA What is

the best next step?

- CXR- PA and lateral views

- Post-op Pneumonia

Post-op fever POD#1 ATELECTASIS PNEUMONIA

DEFINITION Collapse of the lung resulting in imbalance in gas exchange

Pneumonia is an inflammation of the lung tissue as a result of bacterial, viral or other infection.

ETIOLOGY Due to hypoventilation in GA or decreased diaphragmatic movement due to surgical site pain

Complication of atelectasis or aspiration. #1 cause for postop morbidity and mortality. #3 cause for postop complications behind SSI & UTI

PRESENTATION

Fever, tachypnea, tachycardia, dull on percussion over affected area and decreased breath sounds.

Fever, tachypnea, tachycardia, AMS & cyanosis in severe cases; Decreased breath sounds, rales & rhonchi, egophony, dullness on percussion

Post-op fever POD#1 ATELECTASIS PNEUMONIA

INVESTIGATIONS CXR- opacity over affected area - compensatory translucency - ILS hemidiaphragm elevation - mediastinal shift to same sideABG & Helical CT chest

CXR- opacity over affected areaSputum- C & SABG, CBC, CRP

TREATMENT - Adequate pain control- Incentive spirometry for

prophylaxis- Chest physiotherapy- No need for antibiotics- Non invasive +ve pressure

ventilation like CPAP or BiPAP

- Broadspectrum antibiotics according to C&S; No role for spirometry

- Empirically anti Pseudomonal antibiotics like Ceftazidime, Piperacillin- tazobactum, Imipenum, meropenum Etc

- Anti MRSA antibiotics like Vancomycin& Linazolid

Post-op fever POD#1RISK FACTORS: Age > 50 years Duration of surgery > 3 hrs Post-op GCS < 15 Duration of Post-op ETT > 48hrs Tracheostomy Mechanical ventilation ICU stay > 5 days

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