Surgical aspects of fever

Extensive fever workup produces low yield in determining infectious etiology

OBJECTIVE

The study was undertaken to evaluate the use of a fever workup in women undergoing benign gynecologic procedures.

STUDY DESIGN

A retrospective chart review was performed at Jackson Memorial Hospital between 1994 and 2000. Information was abstracted from hospital and clinic records. Fever criteria was defined as 1 temperature equal to or greater than 101.5, or 2 equal to or greater than 100.4, at least 4 hours apart within a 24-hour period. Patients undergoing additional intraoperative procedures leading to increased febrile morbidity were excluded. Data abstracted included patient demographics, procedure, complications, antibiotic use, and extent of fever workup. Statistical analysis used was 2-sample t tests, Wilcoxon rank test, chi2 test, and multivariate logistic regression. Alpha level = .05.

RESULTS

The charts of 505 patients were reviewed, and 147 patients met fever criteria. All patients underwent surgery for benign conditions, abdominal hysterectomy being the most common (90%). The study population was divided into 2 groups: the noninfectious group and infectious group. These groups were determined by wound infection, pelvic abscess, blood or urine culture, ultrasound, and chest roentgen. Both groups were found to be similar with respect to demographics, surgical procedures, and postoperative complications, with the exception of body mass index (28.4 vs 31.7) and length of hospital stay (3.9 vs 5.3). Results from fever workups included positive results blood cultures (9.7%), urine culture (18.8%), and chest roentgens (14%) in this study population. We found no association between positive urine analysis and urine culture. When comparing both groups, a statistically significant difference was found with regard to maximum temperature elevation, number of days febrile, and postoperative day of maximum temperature (P < .05).

CONCLUSION

The extensive fever workup was not frequently positive in this study population. Its use and cost-effectiveness should be questioned. Therefore, the fever workup should be tailored to the individual patient.

Fever after craniofacial surgery in the infant under 24 months of age

A retrospective review was undertaken of 126 consecutive craniofacial procedures involving a transcranial component, performed at the Children's Medical Center at Dallas, between 1990 and 1994. Standard postoperative axillary temperature measurements were recorded until discharge. Age at surgery of less than 24 months correlated very strongly with a postoperative temperature of greater than 38 degrees C (r = -0.92). The incidence of postoperative fever was high in all age groups, yet there was still a significant difference between the group younger than 2 years and the group in which surgery was performed after the age of 2 years across all postoperative temperature ranges, from >38 degrees C to >39.5 degrees C (p < 0.001, chi-square test). The white blood cell count was elevated above the age-related normal in 67 percent of febrile patients. There was no correlation between type or duration of surgical procedure, length of intensive care or hospital stay, or the need for blood transfusion and the development of a significant postoperative fever. There were minor infectious complications in four patients (3 percent), only one of which was a wound problem related to the surgery. All infectious complications were easily identifiable clinically. There was no mortality or serious infections. The development of postoperative fever, and an elevated white blood cell count, is to be expected in pediatric patients undergoing craniofacial procedures. The routine laboratory investigation of postoperative fever in pediatric craniofacial patients under 2 years of age without procedures involving transgression of the paranasal sinuses is not warranted unless there are associated clinical indicators.

Postoperative temperature and infection in patients undergoing general surgery

During a study concerned with postoperative hypothermia, Closs (1985) noted an association between patients' core temperatures in the immediate postoperative period and respiratory infection. In this paper, a small follow-up study is reported in which the relationship between postoperative temperature and the development of infection (respiratory, wound or urinary tract) was investigated in 41 patients who underwent general surgery. Aural and oral core temperatures were monitored at 270, 300 and 330 minutes following return to the ward postoperatively. In the week following surgery, patients were monitored daily for any sign or symptom of infection. Reference was made to the patient, nursing notes, medical notes and physiotherapist (when available). Seven of the 16 patients (44%) exhibiting an aural core temperature of greater than or equal to 37.8 degrees C between 270 and 330 minutes post-return to ward developed infection while five of the 25 patients (20%) exhibiting an aural core temperature of less than 37.8 degrees C developed infection. Oral temperature measurements (using ward mercury-in-glass thermometers) showed a very similar pattern. Overall, infection was detected in 12 of the 41 patients (29%) in the 6 days following surgery, 11 having a respiratory infection and one a wound infection.