The Egyptian Journal of Hospital Medicine (October 2017) Vol.

69 (7) , Page 2771-2776

Causes and Management of Postoperative Fever

Talal Hamid Alfallaj1, Rakan Abdullah Mohammed Aljaafary2, Nouf Ali Alqahtani3,
Khloud Abdulrahman Altowirqi3, Fatmah Ibrahim Alabdullah4, Sara Faisal Bagdood3,
Ali Mohammed Alibrahim5, Asaad Saleh Radwan2, Hassan Mohammed Barnawi6,
Zainab Redaa Alghanim4, Aqeel Ghassan Alhashim4, Eyaad Talat Ghallab7
1 Dow University Of Health Sciences, 2 King Abdulaziz University, 3 Ibn Sina National College,
4 Imam Abdulrahman Bin Faisal University, 5 Tainjin Medical University – China,
6 Taibah University, 7 King Abdullah Medical Complex Jeddah
Corresponding Author: Talal Hamid Alfallaj - Alfallaj_Talal@Hotmail.Com - 054 933 1199

ABSTRACT
Postoperative fever presents a frequent and at times, thorny issue for the clinician. Whereas fever is
frequently a normal phenomenon in the prompt post-surgical period, massive amounts of resources are used
each day in the quest of more unfavorable diagnoses. The occurrence of a postoperative fever is not always
suggestive of an infectious process. Mild temperature rise might be transient in nature and can emerge from
the body's reaction to tissue damage. Fevers that present from two to more than seven days after a surgical
procedure can be caused by other physiological reactions. Perioperative nurses can target nursing
assessments according to the postoperative day on which the fever presents.
Keywords: Fever, Postoperative, Body Temperature, Management, Fever Timing.

INTRODUCTION
Fever is common amid postoperative patients; defined as postoperative. Fever was allied with a
so that postoperative fever is a known term in the significantly higher severity of illness (by
literature even though the fact that the syndrome APACHE II score), but not among those with
has not been well characterized. Furthermore, "postoperative fever." Fever itself was not
postoperative fever is broadly believed to be associated with increased mortality, although
benign and frequently ascribed to non-infectious prolonged fever (>5 days, usually due to infection)
causes [1, 2]. It is assessed that 27-45% of patients was associated thusly. In contrast, early
in intensive care units (ICUs) are febrile at some postoperative fever ensues in fewer than 15% of
point [3,4]. Several examinations show that the non-critically ill patients [10]. The causes of
cause of fever in the ICU is similarly likely to be postoperative fever require better definition [2].
infectious or non-infectious [5, 6]. Among surgical There are several potential causes, including the
patients, fever is more likely because of infection pro-inflammatory response to tissue injury and
as the time interval following surgery increases. surgical stress, the infection that required surgical
Normal body temperature includes an extensive treatment among emergency surgery patients,
variety of values, but for practical purposes a occult community-acquired infection, and surgical
fever has been defined as 38.3oC (100.4o F) and site infections. Potential non-infectious causes
above in ICU patients and may be defined as such include tissue ischemia/infarction, hematoma,
in surgical patients [5, 7]. In the first 48 hours of venous thromboembolic disease, and
the postoperative period a fever is nearly always controversially, atelectasis. Patients may have
non-infectious in origin. The inflammatory more than one cause of fever, and infectious and
mechanisms accountable for postoperative fever non-infectious causes may co-exist. Among
have been the subject of a number of studies. patients with purely infectious causes of fever,
Tissue damages alone results in the disruption of multiple infections may co-exist [10]. The
phospholipids from the cell membrane, leading to evaluation of fever can be protracted and costly [11]
a cascade of prostaglandins and cytokines which due to the low yield of many diagnostic tests, and
ultimately lead to a body temperature elevation [8]. eventually, in as many as 30% of cases [9], the
Nevertheless, fever that continues beyond 96 cause of postoperative fever may never be found.
hours normally warrants further attention. Nevertheless, fever is one clinical indicator of
In a prospective observational study of 93 the pro-inflammatory state identified as systemic
ICU patients, nearly 70% of whom had inflammatory response syndrome [12], which does
experienced elective surgery, a temperature not have benign significances for surgical patients,
elevation to at least 38.4°C was present in 65 particularly when persistent or fully manifest.
cases (70%), more than half of which were simply Talmor et al. [13] studied 2,300 consecutive
2771
Received: 21/09/2017 DOI: 10.12816/0042563
Accepted: 30/09/2017
 Causes and Management of Postoperative Fever

surgical ICU patients, result that persistent in response to tissue damage, and therefore the
systemic inflammatory response syndrome was magnitude of self-limited postoperative fever. For
allied with a higher possibility and a greater instance, youngsters with osteogenesis imperfecta
degree of subsequent organ dysfunction, and an experiencing orthopedic surgery appear to have a
increased mortality rate. Napolitano et al. [15] greater and more sustained febrile response than
established that the attendance of SIRS upon matched controls [19].
hospital admission following trauma was an Bacterial endotoxins and exotoxins can
independent predictor of mortality after wound. empower cytokine discharge and cause
The occurrence of systemic inflammatory postoperative fever. Microscopic organisms or
response syndrome on admission subsequent blunt pieces of microorganisms translocated from the
trauma was a significant independent predictor of colon (e.g., as an outcome of perioperative ileus or
nosocomial infection, which in turn predicted hypotension) might be in charge of a few scenes
mortality. Among the four components of of self-constrained postoperative fever.
systemic inflammatory response syndrome, Lifted levels of bacterial DNA have been
temperature was the most powerful predictor [15]. exhibited with polymerase chain response (PCR)
Furthermore, if systemic inflammatory response testing of blood from surgical patients, even in
syndrome persevered for 7 days after trauma, the patients whose blood societies are negative. Non-
possibility of death was increased nearly five-fold steroidal anti-inflammatory agents (NSAIDs) and
[16]
. glucocorticoids suppress cytokine release and thus
diminish the magnitude of the febrile reaction [20].
MATERIALS AND METHODS
• Data sources and search terms Causes of postoperative fever
We conducted this review using a Postoperative fever can be a side effect of an
comprehensive search of MEDLINE, PubMed, extensive variety of determinations including an
EMBASE, Cochrane Database of Systematic assortment of irresistible causes, for example,
Reviews, and Cochrane Central Register of those starting in the urinary tract, respiratory
Controlled Trials from January 1, 1985, through framework, and wounds, and in addition
June 25, 2017. noninfectious causes, for example, myocardial
• Data extraction dead tissue, pneumonic embolus, and medication
Two reviewers independently reviewed responses [21] (Table 1). It is essential that each
studies, abstracted data, and resolved case of fever is drawn closer in a deliberate way to
disagreements by consensus. Studies were decide the underlying driver. Postoperative fever
evaluated for quality. A review protocol was assessments should consider various variables
followed throughout. including timing (i.e., how soon or how long
postoperatively the patient is), the patient's own
Pathophysiology of postoperative fever particular therapeutic, surgical, and social history,
Fever is an indication of cytokine release in and also points of interest of the system including
response to a range of stimuli [8-10]. Fever- critical occasions involving the patient's
associated cytokines, comprising interleukin (IL)- preoperative, intraoperative, and postoperative
1, IL-6, tumor necrosis factor (TNF)-alpha, and course. Also, a centered physical appraisal and
interferon (IFN)-gamma, are created by a variety any extra indications the patient is encountering
of tissues and cells. There is some evidence that ought to be considered in assessing the clinical
IL-6 is the cytokine most closely correlated with essentialness of a postoperative fever and deciding
postoperative fever [17]. Fever-associated cytokines proper activity. While an entire blood check
are discharged by tissue damage and don't assessing leukocyte tally (white blood cells
certainly signal infection. The extent of the [WBCs]) might be the primary sign of an
damage is associated with the level of the fever irresistible procedure and is normally assessed in
response. the postoperative patient day by day, it is a
For instance, laparoscopic cholecystectomy is nonspecific marker of disease. The WBCs are
allied with less tissue damage and fewer episodes typically raised within the sight of disease; be that
of postoperative fever than is open as it may, in the malnourished or
cholecystectomy. Correspondingly, there is less immunosuppressed patient, they might be
postoperative fever when coronary artery grafting ordinary or decreased also [22]. In this manner,
is done without the utilization of a while WBCs might be a useful marker following
cardiopulmonary bypass pump [18]. Genetic factors disease in some postoperative febrile patients, the
can impact the magnitude of the cytokine release whole clinical picture ought to be analyzed.

2772
 Talal Alfallaj et al.

A cautious review of medications the patient have a generalized maculopapular, pruritic rash
is receiving is imperative as a variation of that may involve the palms and soles. Relative
different medications, comprising certain bradycardia (i.e., a pulse lower than would be
antimicrobial agents, can generate drug fever [23]. expected in the face of the temperature elevation)
See Table 2 for a list of potential medications that indicates a strong possibility of drug fever.
have been known to cause fever. Patients may

Table 1: Causes of postoperative fever

Infectious Noninfectious
Surgical site infection Gout
Pneumonia Hematoma
Urinary tract infection Thyrotoxicosis
Abscess Bowel leak
Pancreatitis Blood transfusion
Cholecystitis Adrenal insufficiency
Clostridium difficile Malignant hyperthermia
Sinusitis Deep vein thromboses
Endocarditis Subarachnoid hemorrhage
Prosthesis infection ETOH/drug withdrawal
Meningitis Medication/drug fever
Myonecrosis Pulmonary embolus
Phlebitis/intravascular related Myocardial infarction
Bacteremia/blood stream infection

Table 2: Causes of drug fever

Antimicrobials Antineoplastic agents
Macrolides Doxorubicin
Isoniazid Chlorambucil
Nafcillin Procarbazine
Ampicillin Cisplatin
Amoxicillin Bleomycin
Piperacillin Hydroxyurea
Penicillin G Methotrexate
Vancomycin 5-Fluorouracil
Gentamiacin Cardiovascular agents
Streptomycin Hydralazine
Amphotericin Captopril
Cephalosporins Procainamide
Trimethoprim-sulfamethazole Quinidine
Central nervous system agents Nifedipine
Phenothiazides Catecholamines
Methyldopa Triamterene
Barbituates Other
Cocaine Allopurinol
Amphetamines Folic acid
Anticholinergic agents Aspirin
Monoamine oxidase inhibitors Ibuprofen
Phenytoin Iodides
Anesthetic agents Cimetidine
Halothane
Enflurane
Succinylcholine

2773
 Causes and Management of Postoperative Fever

Management of postoperative fever injury, and in this manner, these three evaluations
 Fever timing merit extraordinary consideration [2].
Timing after surgery is an essential factor to  Wound evaluation
consider in assessing the etiology of a A patient’s wound ought to be assessed for
postoperative fever. Various investigations have redness, purulent drainage, temperateness, and
been completed in various patient populaces and pain or tenderness, as these all might be
include concurred that inside the initial 48 h after indications of a surgical site infection. In these
surgery, fever is generally a typical part of the cases, a wound culture ought to be sent for
fiery reaction (in view of cytokine discharge examination if conceivable and day by day
because of tissue control or injury) and isn't management ought to be carried out to track for
characteristic of a contamination [2]. An essential expanding or diminishing indications of wound
special case to note is the postoperative febrile infection. In cases of a deeper tissue infection or
patient who creates what is known as harmful an infected hematoma, a radiological imaging
hyperthermia, a possibly deadly autosomal study such as an ultrasound or a CT scan might
overwhelming acquired disorder described most require to be carried out to additional assesses the
prominently by strong unbending nature and to a wound. Furthermore, the wound might need to be
great degree high temperatures (around 40.6◦ C– opened to be fully assessed and refined [22, 28].
41.1◦ C). It is a hypermetabolic express that shows  Respiratory evaluation
with tachycardia, hypercarbia, hypoxemia, On the off chance that a patient is encountering
hyperkalemia, confirmation of rhabdomyolysis, respiratory symptoms postoperatively, for
and arrhythmias [24]. It can happen inside minutes example, shortness of breath, cough, and sputum
or up to 2 days after starting medication generation or their physical examination uncovers
organization of certain sedative specialists, most unusual breath sounds, tachypnea, or diminished
ordinarily succinylcholine and halothane [25, 26]. heartbeat oximetry levels, the primary appraisal
Thusly, the lion's share of postoperative fevers strategy is typically a chest x-beam to assess for
that happen amid the initial 48 h after surgery (and pneumonia. A sputum culture might likewise be
some exploration has even stretched out this helpful to guarantee suitable antibiotics are chosen.
further to postoperative day 5) are for the most Especially in patients after general anesthesia or
part ascribed to the typical incendiary reaction and the individuals who are on drawn out ventilation,
not an irresistible procedure gave the patient is the danger of creating pneumonia is expanded.
generally hemodynamically steady [27]. In Conflicting to common belief, it has been
situations where the patient is hemodynamically exhibited that there is a poor connection amid
precarious, regardless of the planning after atelectasis and postoperative fever such as
surgery, other potential reasons for postoperative atelectasis does not cause fever. On the off chance
fever ought to be considered and suitable work that shortness of breath continues or is the
ups ought to be led. essential worry in a postoperative febrile patient, a
 Focused physical exam computed tomography (CT) scan to assess for
Along with gaining information about the patient's pulmonary embolus might be demonstrated.
past restorative history, kind of surgery, and Patients at expanded danger of creating aspiratory
occasions of their hospitalization, a centered emboli incorporate the individuals who are
physical examination is important as it might stationary, have lower limb immobility, have a
likewise uncover the etiology of postoperative harmful neoplasm, or are taking oral
fever. A great part of the physical examination contraceptives [5]. Pneumonic embolism ought to
and resulting assessment will be guided by every be considered in postoperative febrile patients
patient's specific side effects. What's more, in with unexplained hemodynamic unsteadiness [21,
28]
view of the consequences of the physical .
examination and the patient's side effects, this will  Cardiac evaluation
control the symptomatic investigations that should Myocardial infarction and endocarditis may
be done to absolutely analyze a considerable lot of similarly present postoperatively with fever.
the reasons for postoperative fever. The most Should a patient experience any indications or
widely recognized postoperative diseases are symptoms suggestive of chest pain, an
those including the respiratory framework, the electrocardiogram and cardiac enzymes ought to
genitourinary framework, and in addition the directly be ordered and evaluated. A focused
physical exam ought to be carried out so that the

2774
 Talal Alfallaj et al.

evaluation for any changes in heart sounds or contamination can start as shallow phlebitis and
occurrence of murmurs. Patients with mechanical prompt hazardous bacteremia or sepsis [28].
heart valves are at increased risk of increasing
endocarditis and consequently ought to have an CONCLUSION
echocardiogram carried out to assess for Postoperative fever is frequently a normal
vegetation or infected heart tissue [22]. inflammatory response to surgery, nonetheless it
 Neurological evaluation may similarly manifest from a serious underlying
If a patient felt a symptoms of neck pain infectious or noninfectious origin. Consequently,
confusion, headache, or new neurological deficits it is essential to approach each occurrence of
are revealed on physical examination, a CT scan postoperative fever in a systematic and orderly
ought to be carried out to evaluate for a manner. The diagnostic algorithm displayed
subarachnoid hemorrhage or neoplasm which enables the practitioner a pictorial guide to this
might be the reason of postoperative fever. If a systematic approach. This approach takes into
patient has signs or symptoms indicative of account multiple factors so that suitable diagnostic
meningitis, a lumbar puncture might be essential tests may be ordered to allow cost-effective,
to confirm or exclude this diagnosis [23]. precise, and goal-directed action.

 Abdominal evaluation REFERENCES

In febrile patients who have abdominal pain, 1. Circiumaru B, Baldock G and Cohen J(1999): A
mainly in those who have had abdominal or pelvic prospective study of fever in the intensive care unit.
surgery, a CT scan might be essential. These Intensive Care Med.,25:668-673.
2. Perlino C (2001): Postoperative fever. Medical
patients may have painfulness, protecting, Clinics of North America, 85,1141–1149
firmness, or distention on examination. Many 3. Marik PE(2000): Fever in the ICU. Chest,117:855-
patients after abdominal or pelvic surgery will 869.
have some degree of tenderness that is normal and 4. Clarke DE, Kimelman J and Raffin TA(1991):
predictable after surgery. Regularly it is needed to The evaluation of fever in the intensive care unit.
use approaches of distraction through the Chest,100: 213-220.
examination to evaluate the true degree of 5. O'Grady NP, Barie PS, Bartlett JG et al.(1998):
tenderness. In patients with tenderness, firmness, Practice guidelines for evaluating new fever in
distention, protecting, or peritoneal signs and in critically ill adult patients. Crit Care Med.,26:392-
those who complain of nausea and vomiting, a CT 408.
6. Stumacher RJ(1998): Fever in the ICU. Infect Dis
scan might be essential to evaluate for abscess Pract .,20:89-92.
formation, pancreatitis, cholecystitis, myonecrosis, 7. Garibaldi RA, Brodine S, Matsumiya S and
or bowel leak. Coleman M(1985): Evidence for the non-infectious
In the case of cholecystitis or pancreatitis, etiology of early postoperative fever. Infect Control,
evaluation of serum amylase and lipase levels 6:273.
might support in the diagnosis too. In febrile 8. Held BI, Michels A, Blanco J and Ascher-Walsh
patients with abdominal pain and diarrhea who C (2002): The effect of ketorolac on postoperative
have received antibiotics before or throughout febrile episodes in patients after abdominal
their hospitalization, stool cultures ought to be myomectomy. Am J Obstet Gynecol.,187(6):1450,5;
sent to evaluate for Clostridium difficile [22]. 9. Motagy AK, Khamis I, Kotb M(1993): A
prospective study of postoperative fever A clinical
 Extremity evaluation epidemiologic study. J Egypt Publ Health
A postoperative fever might be characteristic of Assoc.,68:627-637.
profound vein thromboses, so furthest points 10. Meduri GV, Mauldin GL, Wunderonk RG et
ought to be assessed for pain, swelling, and al.(1994): Causes of fever and pulmonary densities
redness, and Homan's sign ought to be checked. A in patients with clinical manifestations of ventilator-
ultrasound of the influenced furthest point ought associated pneumonia. Chest,106:221-235.
to be completed to survey for thromboses. 11. Surshu ED, Kakkifeh B, Pohl JF(1997): Blood
Moreover, intravascular gadgets (both peripheral cultures in febrile patients after hysterectomy. Cost-
and central) ought to be evaluated at and around effectiveness. J Reprod Med.,42:547-550.
12. Bone RC, Balk RA, Cerra FB et al.(1992):
their inclusion destinations for redness, agony, and
American College of Chest Physicians/Society of
swelling and whether they are as yet required Critical Care Medicine Consensus Conference:
every day in the postoperative febrile patient as Definitions for sepsis and organ failure and
these can be a standout amongst the most guidelines for the use of innovative therapies for
incessant wellsprings of nosocomial sepsis. Crit Care Med.,20:864-874.
contamination. Intravascular-related
2775
 Causes and Management of Postoperative Fever

13. Talmor M, Hydo L, Barie PS(1999): Relationship surgical outcome after laparoscopic cholecystectomy:
of systemic inflammatory response syndrome to a randomized double-blind placebo-controlled trial.
organ dysfunction, length of stay, and mortality in Ann Surg.,238:651.
critical surgical illness: Effect of intensive care unit 21. Pile J (2006): Evaluating postoperative fever: A
resuscitation. Arch Surg.,134:81-87. focused approach. Cleveland Clinic Journal of
14. Napolitano LM, Ferrer T, McCarter RJ, Scalea Medicine, 73(1):S62–S66
TM(2000): Systemic inflammatory response 22. Rudra A, Pal S and Acharjee A (2006):
syndrome score at admission independently predicts Postoperative fever. Indian Journal of Critical Care
mortality and length of stay in trauma patients. J Medicine, 10(4): 264–271.
Trauma,49: 647-652. 23. Henker R and Carlson K (2007): Fever: Applying
15. Bochicchio GV, Napolitano LM, Joshi M et research to bedside practice. AACN Advanced
al.(2001): Systemic inflammatory response Critical Care, 18(1): 76–87.
syndrome score at admission independently predicts 24. Heggie J (2002): Malignant hyperthermia:
infection in blunt trauma patients. J Trauma,50:817- Considerations for the general surgeon. Canadian
820. Journal of Surgery, 45: 369–372.
16. Bochicchio GV, Napolitano LM, Joshi M et 25. Cuddy M (2004): The effects of drugs on
al.(2002): Persistent systemic inflammatory response thermoregulation. AACN Clinical Issues, 15(2):
syndrome is predictive of nosocomial infection. J 238–253.
Trauma, 53:245-250. 26. Dalal S and Zhukovsky D (2006): Pathophysiology
17. Mitchell, JD, Grocott, HP, Phillips-Bute, B et and management of fever. Journal of Supportive
al.(2007): Cytokine secretion after cardiac surgery Oncology, 4: 9–16.
and its relationship to postoperative fever. 27. Lim E, Motalleb-Zadeh R, Wallard M, Misra N,
Cytokine,39:37. Akowuah E, Ahme, I et al. (2003):Pyrexia after
18. Clark JA, Bar-Yosef S, Anderson A et al.(2005): cardiac surgery: Natural history and association with
Postoperative hyperthermia following off-pump infection. Journal of Thoracic and Cardiovascular
versus on-pump coronary artery bypass surgery. J Surgery, 126:1013–1017.
Cardiothorac Vasc Anesth.,19:426. 28. O’Grady N, Barie P, Bartlett J, Bleck T, Carroll
19. Ghert M, Allen B, Davids J et al.(2003): Increased K, Kalil A et al. (2008): Guidelines for evaluation of
postoperative febrile response in children with new fever in critically ill adult patients: 2008 update
osteogenesis imperfecta. J Pediatr Orthop.,23:261. from the American College of Critical Care Medicine
20. Bisgaard T, Klarskov B, Kehlet H, Rosenberg and Infectious Diseases Society of America. Critical
J(2003): Preoperative dexamethasone improves Care Medicine, 36: 1330–1344.

2776