Historically, the standard definition of febrile morbidity for surgical patients was the presence of a temperature higher than or equal to 100.4◦F (38◦C) on two occasions at least 4 hours apart during the postoperative period, excluding the first 24 hours. Other sources defined fever as two consecutive temperature elevations greater than 101.0◦F (38.3◦C) (79,80). Febrile morbidity is estimated to occur in as many as one-half of patients; it is often self-limited, resolves without therapy, and is usually noninfectious in origin (81). Overzealous evaluations of postoperative fever, especially during the early postoperative period, are time consuming, expensive, and sometimes uncomfortable for the patient (81). The value of 101.0◦F is more useful than 100.4◦F to distinguish an infectious cause from an inconsequential postoperative fever.
The assessment of a febrile surgical patient should include a review of the patient’s history with regard to risk factors. Both the history and the physical examination should focus on the potential sites of infection (Table 22.9). The examination should include inspection of the pharynx, a thorough pulmonary examination, percussion of the kidneys to assess for costovertebral angle tenderness, inspection and palpation of the abdominal incision, examination of sites of intravenous catheters, and an examination of the extremities for evidence of deep venous thrombosis or thrombophlebitis. In gynecologic patients, an appropriate workup may include inspection and palpation of the vaginal cuff for signs of induration, tenderness, or purulent drainage. A pelvic examination should be performed to identify a mass consistent with a pelvic hematoma or abscess and to look for signs of pelvic cellulitis.
Patients with fever in the early postoperative period should have an aggressive pulmonary toilet, including incentive spirometry (80). If the fever persists beyond 72 hours postoperatively, additional laboratory and radiologic data may be obtained. The evaluation may include complete and differential white blood cell counts and a urinalysis. In one study, results from fever workups included positive blood cultures in 9.7% of patients, a positive urine culture in 18.8%, and a positive chest x-ray in 14%. These data support the need for a tailored workup based on the patient’s clinical picture (82). Blood cultures can be obtained but will most likely be of little yield unless the patient has a high fever (102◦F). In patients with costovertebral angle tenderness, intravenous pyelogram may be indicated to rule out the presence of ureteral damage or obstruction from surgery, particularly in the absence of laboratory evidence of urinary tract infection. Patients who have persistent fevers without a clear localizing source should undergo CT scanning of the abdomen and pelvis to rule out the presence of an intra-abdominal abscess. If fever persists in patients who had gastrointestinal surgery, a barium enema or upper gastrointestinal studies with small bowel assessment may be indicated late in the course of the first postoperative week to rule out an anastomotic leak or fistula.
Table 22.9 Posthysterectomy Infections
Urinary Tract Infections Historically, the urinary tract was the most common site of infection in surgical patients (83). The incidence reported in the gynecologic literature is less than 4% (84,85). This decrease in urinary tract infections is most likely the result of increased perioperative use of prophylactic antibiotics. The incidence of postoperative urinary tract infection in gynecologic surgical patients not receiving prophylactic antibiotics is confirmed to be as high as 40%, and even a single dose of perioperative prophylactic antibiotic decreases the incidence of postoperative urinary tract infection to as low as 4% (86,87).