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Fever Plus Tachycardia Suggest Infection After Surgery


 

Expert Analysis from an International Pelvic Reconstructive and Vaginal Surgery Conference

ST. LOUIS — Postoperative fever in a patient who has undergone gynecologic surgery doesn't necessarily indicate infection.

In fact, fever without tachycardia – even if the fever is high – is most likely “drug fever,” which is commonly associated with antibiotics. A single dose of antibiotics that is given prophylactically could cause this, Dr. Sebastian Faro said at the conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.

“I do a physical exam on all these patients, and if I don't find anything on my exam, I stop her drugs. This patient should become afebrile within 24–36 hours” if it's drug fever, said Dr. Faro, professor and vice chairman of the department of obstetrics, gynecology, and reproductive sciences at the University of Texas Health Science Center at Houston.

He said residents will often ask, “What if she's really infected?”

If the antibiotics are discontinued and the patient is indeed infected, then the signs and symptoms of the infection will manifest themselves and different antibiotics can be instituted. Localization of the infection may be realized with further evaluation.

“I have never had a patient's condition deteriorate and [the patient] become critically ill or die from stopping antibiotic therapy” when she has a fever plus a normal pulse rate, normal blood pressure, and good urine output, Dr. Faro said.

Conversely, spiking temperatures with a parallel pulse rate is an indication of infection. “This is the hallmark for me, which makes me come in and evaluate that patient,” he said.

This isn't tachycardia associated with anemia, he added, noting that tachycardia with anemia doesn't follow the temperature curve.

When both fever and tachycardia are present, you need to examine the patient, said Dr. Faro, who is also chief of obstetrics and gynecology and clinical medical director at Lyndon B. Johnson Hospital, Houston.

Consider it a fever if the oral body temperature is 101° F or greater, or if it's 100.4°–101° F as measured on two occasions at least 6 hours apart. Do expect infection if fever is present and the pulse rate is 100 beats per minute or greater, he said.

A white blood count is also important for identifying infection, he said.

White cell counts go up in the first 24 hours, so Dr. Faro suggests obtaining a count 6 or more hours after surgery, and obtaining another early the next morning.

If the count is high the night before but has decreased in the morning, that's good. If it hasn't declined, the patient needs to be evaluated. Check blood pressure and urine output, he said.

“One of the most subtle signs [of infection] is oliguria,” he said, explaining that oliguria can be secondary to dehydration.

If a patient with oliguria is febrile and doesn't respond to fluids in an hour – Dr. Faro recommends a 550-cc bolus in a patient with healthy kidneys – the patient may have sepsis, he said.

Dr. Faro disclosed that he is a consultant for American Medical Systems Inc.

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