Postoperative Fever Medical Slides

Present the mnemonic with evidence-based updates: Wind (POD 1-2) — traditionally atelectasis, but a 2011 meta-analysis (Mavros) found no evidence that atelectasis causes fever; early fever is likely cytokine-mediated. Water (POD 3-5) — UTI (especially with indwelling catheter >48 hours, UA + culture only if symptomatic). Walking (POD 4-6) — DVT/PE (clinical suspicion → D-dimer/CTA, not routine screening). Wound (POD 5-7) — SSI (inspect wound, culture only if purulent drainage). Wonder Drug (any time) — drug fever (beta-lactams most common, diagnosis of exclusion, eosinophilia in 20%). Add a 6th W: "What did we do?" — procedure-specific complications (anastomotic leak after bowel surgery, cholangitis after biliary surgery).

Present the evidence: Roberts (2019, Ann Surg) — blood cultures obtained for POD 0-2 fever had <5% positivity rate and rarely changed management. Suwanasawong (2019) — chest X-rays for early postoperative fever had <2% clinically significant findings. Pan cultures (blood, urine, CXR) for early fever without localizing signs have a combined diagnostic yield <10% and cost >$500 per episode. Evidence-based approach: POD 0-2 fever without localizing signs → physical exam, incentive spirometry, reassurance (no cultures). POD 3+ fever → targeted workup based on clinical assessment. Any fever with hemodynamic instability, immunosuppression, or prosthetic implant → aggressive early workup.

Present C. difficile as an increasingly important cause of late postoperative fever: any patient with fever + diarrhea after antibiotic exposure (including surgical prophylaxis) should be tested for C. difficile toxin. Incidence in surgical patients: 1-2% after colorectal surgery, higher with prolonged postoperative antibiotics. IDSA 2021 guidelines: PCR or GDH/toxin two-step testing. Treatment: initial non-severe episode → oral vancomycin 125 mg QID × 10 days (fidaxomicin preferred for recurrence prevention). Severe (WBC >15,000, Cr >1.5) → oral vancomycin 500 mg QID. Fulminant (hypotension, ileus, megacolon) → oral vancomycin 500 mg QID + IV metronidazole 500 mg q8h, consider colectomy if refractory. Prevention: antibiotic stewardship is the most effective strategy.