POSTOPERATIVE COMPLICATIONS
What is the most likely diagnosis?
a. Atelectasis
b. Pneumonia
c. Urinary tract infection
d. Deep venous thrombosis
e. Wound infection
Answer b. Pneumonia
The most likely cause of fever on the first through third postoperative day is pneumonia or wind. The underlying cause of pneumonia can be bacterial infiltration or aspiration.
An incentive spirometer prevents atelectasis but does not prevent pneumonia.
Anterior hypothalamus is responsible for cooling; the posterior is responsible for heating.
What is the best next step in the management of this patient?
a. Chest radiography
b. Blood cultures
c. Start antibiotics
d. Sputum culture
e. Check for a cough
Answer a. Chest radiography
The best next step in the management of this patient is to obtain posterior-anterior and lateral chest radiographs. It is always the wrong answer to obtain a portable chest radiograph for anything other than line or tube placement. Obtaining blood cultures will not help in diagnosis pneumonia but only for bacteremia, and starting antibiotics is only after the pneumonia is confirmed. Sputum is only available in up to one third of patients with pneumonia, and therefore it is not routinely done. Cough is not necessarily seen in all patients with pneumonia and therefore is also not reliable for diagnostic purposes.
Interleukin 1 (IL-1) release causes fever by stimulating the hypothalamus.
Benefits of fever:
• Increased mobility of leukocytes
• Enhanced leukocyte phagocytosis
• Decreased endotoxin effects
• Increased proliferation of T cells
Surgery or intubation makes HCAP possible even before the 48-hour mark.
Treating HCAP when pseudomonas is likely requires vancomycin with two of the following:
• Antipseudomonal cephalosporin (cefepime, ceftaroline)
• Carbapenem (imipenem, meropenem)
• β-Lactam/β-lactamase inhibitor (piperacillin–tazobactam, ticarcillin–clavulanic acid)
• Fluoroquinolone (levofloxacin, moxifloxacin)
• Aminoglycoside
• Monobactam (aztreonam)
What is the most likely diagnosis?
a. Atelectasis
b. Pneumonia
c. Urinary tract infection (UTI)
d. Deep venous thrombosis (DVT)
e. Wound infection
Answer c. Urinary tract infection (UTI)
The most likely diagnosis for fever on the third postoperative day is a catheter-associated urinary tract infection (CAUTI). A Foley catheter is a foreign body and therefore is a nidus for infection. The risk of a CAUTI increases with the duration of catheterization. Common misconceptions regarding prevention of CAUTI include prophylactic antibiotics, using iodine-based sterile techniques for insertion, and flushing the catheter. The only way of preventing a CAUTI is early removal of the catheter.
UTI is more common in patients who have undergone a genitourinary procedure.
What is the best next step in the management of this patient?
a. Urinalysis (UA)
b. Urine culture
c. Start antibiotics
d. Remove the Foley catheter
e. Flush the Foley line with vancomycin
Answer d. Remove the Foley catheter
The best next step in the management of this patient is the removal of the Foley catheter. The patient is able to sit in a chair, is ambulatory, and no longer requires a Foley catheter. Obtaining UA and urine culture is important for diagnostic purposes, but removing the Foley catheter is more important. Otherwise, you are not treating the true underlying cause of the UTI. After obtaining urine for analysis, it is then paramount to start antibiotics. Flushing the line with vancomycin or any antibiotic has never been shown to treat a UTI.
The most common organisms in CAUTI are Escherichia coli #1 and enterococci #2.
The most common organism for UTI after coitus is Staphylococcus saprophyticus.
Leukocyte esterase is surrogate marker for WBCs in the urine.
Order:
• Start empiric antibiotics, such as ciprofloxacin, to treat for the most common cause of UTI, E. coli.
CCS TIP: Turn the clock forward after starting antibiotics, and the case will end. However, if the case does not end, turn the clock forward 3 days. This will give you a culture result. Tailor antibiotics to the given sensitivities and organism and then turn the clock forward. The case will end.
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