Fever

Fever

Nov 5, 2014 0
General medicine,infectious diseases,onthepods

James talks to Dr Andie Lee about an approach to fever on the wards, particularly a new fever in a post-op patient.

Script Writer:  Abhijit Pal

Summary Writer:  Abhijit Pal

Editor:  James Edwards

Interviewee:  Andie Lee

About Dr Andie Lee

Dr Andie Lee is a Staff Specialist in Infectious Diseases and Microbiology at Royal Prince Alfred Hospital, Sydney. Andie is a Clinical Senior Lecturer at the University of Sydney. She has an interest in healthcare-associated infections, particularly due to multi-resistant Gram positive bacteria, as well as the transmission dynamics of infectious diseases. Andie was previously a Research Fellow at the University of Geneva Hospital in Switzerland where she coordinated a European multicentre clinical trial evaluating the effectiveness of interventions to control methicillin-resistant Staphylococcus aureus in hospitals.

Fever

With Dr Andie Lee, Infectious Diseases Consultant at Royal Prince Alfred Hospital, New South Wales, Australia

Case

You are asked to see a patient with fever. He is Day 4 post anterior resection of a colorectal carcinoma. It is important to bear in mind the context in which you are getting called – this is a new fever in a post-op patient.

  • Magnitude and duration of fever
    • the height of the fever is not necessarily indicative of whether or not someone has an infection
    • post-operative patients commonly have fever, and if it’s been a low grade fever present since the surgery, then it is less of a concern that someone with a high, new fever.
  • Vital signs to triage urgency
    • Tachycardia is expected but if the heart rate is very high (e.g. >140-150) may suggest arrhythmia
    • Hypotension is concerning for septic shock
    • RR and oxygen saturations if abnormal may suggest hospital-acquired pneumonia
  • Original reason for admission
  • Any associated symptoms
  • General observation: looking well or looking unwell
  • Look at pattern of the fever and BP on observation chart
  • If they don’t look too unwell, review progress notes e.g. operation notes – complications, prolonged procedure, team concerns then take a history and examine the patient.
  • Non-infective causes
    • Pulmonary embolism
    • Drugs
    • Malignancies or other inflammatory conditions (but uncommon, must exclude infection and PE first)
  • Infective causes
    • surgical site infections (e.g. superficial wound infections, dehiscence of the anastamosis and intra-abdominal collections)
    • UTI (especially in presence of IDCs)
    • Cannula site infection or line sepsis
    • Pneumonia secondary to diaphragmatic splinting from post-operative pain and reduced clearing of their secretions.
  • Day 0: could be related to infection at the time of surgery (e.g. intra-abdominal infection from bowel perforation prior to anterior resection), drug/transfusion reactions
  • Day 1-2: more commonly post-operative non-infective fever from tissue breakdown or pulmonary atelectasis
  • Day 3-4: infection becomes more likely, for e.g. from invasive devices or procedures.
  • Day 7 or more: PE?
  • Skin: cannula site erythema/discharge
  • IDC: good drainage (infection can cause obstruction), urine clear vs cloudy
  • Signs for DVT (calf swelling/pain)
  • Cardio-respiratory exam (?pneumonia) and abdominal exam (inspecting surgical site)
  • Minimum one set of blood cultures (aerobic plus anaerobic bottle) but recommend 2 sets from 2 sites, and 3 if suspecting infective endocarditis
    • one set picks up ~60% of bacteraemia
    • two sets pick up 90-95% of bacteraemia
    • also helps in interpretation of positive blood cultures that may be related to skin commensals – particularly important in patients with prosthetic joints/devices/catheters or suspecting infective endocarditis
    • try and space out collections over time, if not starting antibiotics straight away
  • Urine MCS
  • Others depending on clinical findings:
    • Wound swabs
    • Central line site swab if it is oozing
    • Line tip culture if lines are being removed
    • CXR if signs of respiratory tract infection
  • Special group of patient as they are immunosuppressed and at higher risk of bacterial sepsis and shock
  • Need to prioritise and assume it is an infection until proven otherwise
  • If it is a new fever – assess the patient’s vitals, history (symptoms of infection), examination and antibiotic history
    • Often this group have a lot of diarrhoea as a result of chemotherapy
    • Often have deep lines in – which can become infected
    • At risk of respiratory infections – bacterial and viral
    • Two sets of blood cultures should be collected (if recent collection, may get away with just doing one). Consider peripheral and line access cultures and label appropriately
  • Febrile neutropenic patients need to be given antibiotics
    • Use broad spectrum cover
    • Needs to include pseudomonas as they are at increased risk of pseudomonas infections – includes tazocin + gentamicin; some sites use amikacin instead of gentamicin if hemodynamically unstable
  • Speak to the haematologist on call for advice around antibiotics and management of these patients

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Tags: #Blood cultures,#fever,#hypotension,#infections,#inflammation,#neutropaenia,#neutrophil,#PE,#sepsis,#septic screen,#septic shock,#tachycardia

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