Post operative Fever in OMFS patients

Ryaz Ansari OMFS clinics of NA 2006: 73-79

DEFINITION
Diurnal variation lowest oral temperature at 6:00 am and the maximum at 4:00 pm. Fever is defined as a temperature of greater than 37.2C (99F) in the early morning or greater than 37.7C (100F) in the late afternoon.

THE DIFFERENCE
FEVER: is a sign of inflammation (not infection); it is a response to the release of inflammatory cytokines (ie, tumor necrosis factor and interleukin [IL] 1b). HYPERTHERMIA: hypothalamic center remains unchanged, whereas body temperature increases uncontrollably. Eg.Heat stroke, MH

 HYPERPYREXIA: is used for excessively high fevers greater than 41.5C.

Chemical mediators of fever

Exogenous pyrogens - microbial origin, known as toxins. Endogenous pyrogens /pyrogenic cytokines Cytokines are small proteins that regulate immune, inflammatory, and hematopoietic processes. These are IL-1, IL-6, and tumor necrosis factor.

CLASSIFICATION
Post-operative fever is classified as immediate, (0-24hrs) acute (2472 hours postoperatively), subacute (within the first week), or delayed.

Immediate fever 0-24hrs

Medication Blood products Infection before Sx Trauma during Sx Drug reactions (rash+hypotension) Infection - Clostridium perfringens / Steptococcus group A

 Fevers as a result of drugs five categories: I. hypersensitivity reactions, II. altered thermoregulatory mechanisms, III. related directly to administration of the drug, IV. direct extensions of the pharmacologic action of the drug, V. idiosyncratic reactions diagnosis by exclusion sequential manner

Drugs capable of inducing fever

Fever due to transfusion rxn

Mild - no treatment Major - tachycardia, chills, back pain, dyspnea, or microvascular bleeding Stop transfusion Significant hemolysis forced diuresis and alkalization of the urine to prevent renal toxicity

Acute fever 24 72 hrs

Atelectasis, Surgical site infection, Intravascular catheters Aspiration pneumonia, Pulmonary embolism, UTI , DVT, Aspiration pneumonia

Atelectasis
defined as the collapse or closure of alveoli resulting in reduced or absent gas exchange atelectasisbis 56% predictor of fever Prolonged Sx- mucus build up obstructed bronchiole collapsed segment tissue breakdown bacterial invasion febrile response. Trt : ambulation / deep breathing / physio

UTI
In patients with catheters Longer duration increases risk Females > male short urethra Flank pain, burning, cloudy urine E.coli most common Urine culture + antibiotics

P.O Fever due to IV Catheters

I. Phlebitis inflammed vessel 2-45% II. Thrombophlebitis Phlebitis + clot III. Septic thrombophlebitis Infected clot Signs localized redness, warmth , tenderness and fever Remove hardware, analgesic + antibiotic

Sx site infection
Examine Sx site everyday Look for swelling, erythema, pain, discharge, and possible dehiscence. presence of pus - indication to open the wound. Cultures should determine antibiotic coverage.

Malignant Hyperthermia
Genetic disorder (gene - RYR1) Precipitated halothane / succinylcholine uncontrolled efflux of calcium from sarcoplasmic Reticulum- tetany - increased skeletal metabolism - heat production,. Increase in the end-tidal carbon dioxide Muscle rigidity (masseter stiffness), sinus tachycardia, skin cyanosis & significant hyperthermia (45C) Trt: Dantrolene sodium 2mg/Kg IV

Subacute bacterial endocarditis

fever, fatigue, anorexia, back pain, and weight loss ,Less common CVA Strep viridans

Dx of P.O.F

Treatment
Accurate diagnosis Physical examination Lab studies Anti microbial Anti pyeretic