Avoiding harm: the early postoperative fever

One of the most important principles in medicine is to avoid doing harm to your patients. This is easier said than done because sometimes things that are iatrogenic are confused for natural evolutions of the disease process. That leads to writing the first post in a series entitled ‘avoiding harm’.

One good example is the early postoperative fever. I use this term to mean fever occurring in the initial 24-48 hour post operative period. As a house officer my friends and I spent many hours taking blood cultures on these patients, obtaining chest X-rays and chasing urine samples.

Eventually I realised what would happen is we would treat areas of atelectasis that were confused for pneumonia, colonised (but not infected) bladders and skin contaminants on blood culture. All of this represented unnecessary exposure to antibiotics, which have the potential to seriously harm patients.

Fortunately all of this can be avoided. There are 11 articles in the literature which I have taken the time to find for you. They uniformly tell us that if there is no sign of focal infection on clinical exam, the ‘septic screen’ can be safely forgone.

Blood cultures were the most useless. In four studies the pick up rate on blood cultures (excluding contaminant results) was zero. Two of these studies were designed specifically to look into the utility of blood cultures. All studies had large numbers of patients. One study found that of 38 blood cultures only 1 was positive and this was on post-operative day 16. Two further studies reported a 6-7% rate of positive blood cultures. The pick up rate of chest Xrays and urine cultures was about 10%.

Four studies reported that in those patients who were diagnosed with an infection, the majority of the time the source was identifiable based on physical exam and clinical picture, or that the clinical picture guided the need for further investigations.

Three studies actually attempted to quantify the cost. One calculated a cost of $8000 per change in clinical management, one worked out $2000 per infection diagnosed and one concluded that “rote” ordering of tests resulted in a total of $20000 (or $278 per patient) excess expenditure. All eleven studies concluded that “routine” ordering of investigations for early post-operative fever was unnecessary and costly.

  1. Sivakumar B, Vijaysegaran P, Ottley M, Crawford R, Coulter C. Blood cultures for evaluation of early postoperative fever after femoral neck fracture surgery.  J Orthop Surg (Hong Kong). 2012 Dec;20(3):336-40.
  2. Bindelglass DF, Pellegrino J. The role of blood cultures in the acute evaluation of postoperative fever in arthroplasty patients. J Arthroplasty. 2007 Aug;22(5):701-2.
  3. Lesperance R, Lehman R, Lesperance K, Cronk D, Martin M. Early postoperative fever and the “routine” fever work-up: results of a prospective study. J Surg Res. 2011 Nov;171(1):245-50. doi: 10.1016/j.jss.2010.03.009. Epub 2010 May 11.
  4. Fanning J, Neuhoff RA, Brewer JE, Castaneda T, Marcotte MP, Jacobson RL. Yield of postoperative fever evaluation. Prim Care Update Ob Gyns. 1998 Jul 1;5(4):146.
  5. Petretta R, McConkey M, Slobogean GP, Handel J, Broekhuyse HM. Incidence, risk factors, and diagnostic evaluation of postoperative fever in an orthopaedic trauma population. J Orthop Trauma. 2013 Oct;27(10):558-62.
  6. Ward DT, Hansen EN, Takemoto SK, Bozic KJ. Cost and effectiveness of postoperative fever diagnostic evaluation in total joint arthroplasty patients. J Arthroplasty. 2010 Sep;25(6 Suppl):43-8. doi: 10.1016/j.arth.2010.03.016. Epub 2010 May 10.
  7. de la Torre SH, Mandel L, Goff BA. Evaluation of postoperative fever: usefulness and cost-effectiveness of routine workup. Am J Obstet Gynecol. 2003 Jun;188(6):1642-7.
  8. Athanassious C, Samad A, Avery A, Cohen J, Chalnick D. Evaluation of fever in the immediate postoperative period in patients who underwent total joint arthroplasty. J Arthroplasty. 2011 Dec;26(8):1404-8. doi: 10.1016/j.arth.2011.02.019. Epub 2011 Apr 7
  9. Czaplicki AP, Borger JE, Politi JR, Chambers BT, Taylor BC. Evaluation of postoperative fever and leukocytosis in patients after total hip and knee arthroplasty. J Arthroplasty. 2011 Dec;26(8):1387-9. doi: 10.1016/j.arth.2010.12.024. Epub 2011 Feb 25.
  10. Verkkala K, Valtonen V, Järvinen A, Tolppanen EM. Fever, leucocytosis and C-reactive protein after open-heart surgery and their value in the diagnosis of postoperative infections. Thorac Cardiovasc Surg. 1987 Apr;35(2):78-82.
  11. Freischlag J, Busuttil RW. The value of postoperative fever evaluation. Surgery. 1983 Aug;94(2):358-63.

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