Surgical Pearls

Ahhh Crap! My Patient has Post Operative Fever!

2009-02-02T12:46:00.000-08:00

Post operative fever is temperature above 38.5 Celcious or 101.5 farenheight

Post Op Fever 5 W’s and a Basic Diagnostic Plan

Pre 24 hour fever- Early atelectasis, wound infected by B-haemolytic strep or cloistridium, anastomtic leak.

Wind – Is this atelectasis or Pneumonia? First 24- 48 hours

Water – Is this a Urinary Tract infection? Anytime after post op day 3
Wound – Take a peek, remove dressings if needed, is your wound infected? Anytime after post op day 5
Walking – Is this a PE? Day 7-10
Wonder drugs – check all the meds Your patient is on! Occurs anytime!

Obviously your management work up depends upon the cause of your post op fever. The work up for a PE is obviously different than draining a collection of pus. Both should be considered if your patient is not responding to your current course of antibiotics.

Basic Diagnostic Plan

CXR
Blood cultures (two sets differnt locations)
Urine analysis, Culture and sensitivity
Other images needed?

Where the hell could this infection be coming from?

Central line?
Foley catheter?
Pulmonary emboli?
Heparin lock or IV?
Urinary tract?
Patients wound?
Heart Valves?
(you can always call you local microbiologist)

Out of ideas...What the hell should I do next?

Antibiotics (but wait!)?
Culture everything first!
Blood cultures X 2
Did you culture: Urine, Sputum, all the ports of all these lines?
Do you need to give your patient more IV fluids (if your patient has fever their fluid requirements go up ya know!)

Are you still totally lost? Should you have called the infectious disease consultant 5 minutes ago?

Beware the groin, neck or antecubital “abscess”

2009-02-01T09:42:00.000-08:00

Today I was reading a short piece in Avoiding Common Surgical Errors (ACSE) which admonished “Do not Incise and Drain an abscess in the antecubital fossa, groin or neck in the Emergency Room”.

The surgical resident is commonly called to evaluate red, tender, fluctuant masses all over the body and often incises and drains an abscess under local anaesthesia. These masses are often numbed with ethyl chloride spray and acupressure (lignocaine doesn't work well in an acid environment and pus has a low pH) before a cruciate incision is made, the contents are evacuated, samples taken for culture and the wound is packed with a Betadine wick.

In the book, Dr. Schneider reminds readers, however, that if the mass is in the antecubital fossa, groin or neck we should consider mycotic aneurysm in our differential.

A mycotic aneursym is a localised dilatation of an artery at least 150% of its normal diameter due to destruction of the vessel wall by bacterial infection। Usually this is due to penetrating injury, most commonly in IVDUs. Dr. Fiser (ABSITE Review) says that the organism responsible is most commonly Staph. or Strep., and that empiric broad spectrum antibiotic cover (e.g. Flucloxacillin 500mg tds iv + benzyl-penicillin 1.2g qds iv) should be started.

Dr. Schneider argues that mistakenly unroofing a mycotic aneurysm can cause life-threatening haemorrhage and so if you are suspicious, I&D under local in the ER is verboten without first:

assessing the lesion clinically (for a pulse and bruit) and if necessary
imaging it with Doppler ultrasound or CT angiography.

If the vessel isn't radiologically involved then go for it, otherwise dissection and repair will need to take place in the OR. Operative repair includes ligation of the vessel if there is sufficient collateral supply, and vein graft if there isn't.

This led me on to starting the chapter on “Methods of Arresting Bleeding” in Milton T. Edgerton's very excellent “The Art of Surgical Technique”, but I haven't finished, so I'll report back on that later!

GAB

Books I Liked:

Test POST 1

2009-01-31T15:07:00.001-08:00

"A poor surgeon hurts 1 person at a time. A poor teacher hurts 130." -Ernest Boyer