Postoperative fever

Problem 2 Postoperative fever



Wendy A. Brown




A 25-year-old woman presents back to the emergency department 10 days following an open appendicectomy for perforated appendicitis. She was discharged 5 days ago but she now has swinging fevers, rigors and complains of constant abdominal pain which is worse with movement and coughing. On examination her pulse rate is 100/min, blood pressure 110/80 mmHg, temperature 38.5°C, respiratory 10 breaths/min, and her oxygen saturation is 98% breathing room air. Her wound is red and swollen but there is no discharge. She is tender in the lower abdomen and on rectal examination an area of fullness is noted anterior to the rectum.



Q.1


What is the differential diagnosis?


As part of her initial management the patient will require some investigations and treatment.



Q.2


What investigations are required at this stage – and why?


While the various investigations are arranged, treatment must be started.



Q.3


What treatment is required at this stage?


A CT scan of the abdomen is performed. One slice is shown.


image

Figure 2.1



Q.4


What does the image show and what should be done?



Answers


A.1 The most likely diagnosis is a pelvic collection or abscess. Other conditions to consider include a wound infection, urinary or chest infection. A pneumonia is unlikely given this clinical picture.


A.2 Her laboratory studies should include a full blood count (a leucocytosis would support the diagnosis of infection), C-reactive protein (inflammatory response) and electrolytes (dehydration). She is likely to have a septicaemia and blood cultures may help identify the organism(s) and help target antibiotic therapy. A chest X-ray and urinalysis are also required to exclude the respiratory and renal tracts as sources of sepsis. As the most likely source of sepsis is within the abdomino-pelvic cavity some form of imaging is required and a CT scan would be most appropriate.


As the patient is septic she may be coagulopathic and her clotting profile should be established.


A.3 Oral fluids must be withheld in case some procedure or operative intervention is required. Intravenous fluids should be started (see Problem 1) and broad-spectrum antibiotics given on a empirical basis. These should cover Gram-positive cocci and rods and Gram-negative rods and anaerobes. Possible combinations of antibiotics might include ceftriaxone and metronidazole or amoxicillin, gentamicin and metronidazole.


A.4 There are several collections of fluid in the pelvis and specifically in Morrison’s pouch. There is also a small collection of fluid in the subcutaneous tissues in the region of the skin incision. The wound needs to be opened. Percutaneous drainage of the pelvic collections needs to be considered. If not feasible, the patient may require open drainage. The antibiotics must be continued and adjusted if need be, depending on the sensitivities of any organisms grown.

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Postoperative fever

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