Version May 2024
| Postoperative fever definition and causes |
| Temperature >38°C (100.4°F) |
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| Fever can be a normal response to surgery or be due to another cause. |
| Infection is only one of the other possible causes. |
| Most early postoperative fevers are due to surgical trauma. |
| Most patients with fever after the third postoperative day have an infection. |
| Noninfectious causes of fever that are potentially life-threatening can occur in the immediate and early postoperative periods. |
| Evaluation |
| Patient characteristics |
| Review medical record for allergies, medications, preexisting medical conditions. |
| Review medical record for fever complicating prior surgeries. |
| Recent medical history |
| When was the surgery? What was the nature of the surgery? |
| Was the surgery under emergency circumstances or elective? Were there intraoperative complications? |
| What types of catheters/devices/drains were placed, and when were they placed? |
| Ask the patient and nurse about pain; cough; sputum production, quality, and volume; skin changes; and diarrhea. |
| Physical examination |
| Review record for vital signs, including peak and trough values since surgery. |
| Examine the skin for rash, erythema, ecchymosis, hematoma, and pallor. |
| Auscultate the lungs for crackles, wheezes, and for the absence of breath sounds in dependent and apical regions. |
| Auscultate the heart for murmurs, gallops, and rubs. |
| Evaluate the abdomen for tenderness, distention, and hyperactive or hypoactive bowel sounds. |
| Examine the surgical site for erythema, swelling, tenderness, and drainage. |
| Examine catheter, tube, and drain sites for erythema, swelling, tenderness, and drainage. |
| Evaluate the extremities for edema, erythema, duskiness, and tenderness. |
| Laboratory |
| Comprehensive laboratory screening is not indicated for most patients. Specific laboratory or radiographic studies may be indicated by specific history and physical examination findings. |
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| Others based on specific findings: Abdominal CT scan for abdominal pain, hepatic and pancreatic enzymes following upper gastrointestinal surgery, extremity ultrasound for suspected deep vein thrombosis. |
| Consider less common causes of fever (may require emergency management) |
| Myocardial infarction, pericarditis (Dressler syndrome), pulmonary embolism, anastomotic leak, necrotizing soft tissue infection, alcohol withdrawal, thyrotoxicosis, adrenal crisis, endocarditis, malignant hyperthermia, or cerebral infarction/hemorrhage |
| Evaluate for more common causes of fever |
| Infectious |
| Surgical procedure associated (eg, surgical site infection, intra-abdominal abscess, cholangitis, osteomyelitis, meningitis) |
| Nosocomial infection (eg, pneumonia, urinary tract infection, intravascular device-related bloodstream infection, antibiotic-associated diarrhea, infusion-related infection) |
| Others (eg, acalculous cholecystitis, sinusitis, otitis media, prostatitis, endocarditis) |
| Transfusion-associated viral infections |
| Noninfectious |
| Surgical procedure associated (eg, bowel ischemia, pancreatitis, transplant rejection) |
| Surgical site inflammation without infection (eg, hematoma, seroma, foreign body reaction [eg, suture, prosthetic mesh, vascular graft material]) |
| Deep vein thrombosis/superficial vein thrombosis |
| Transfusion reaction |
| Gout/pseudogout |
| Neoplasia |
| Medications |
| Treatment |
| General measures |
| Resuscitation, as needed. |
| Control pain. |
| Antipyretics – Acetaminophen is often appropriate to reduce fever but should be avoided in patients with alcohol use disorder, starvation, or hepatic impairment. |
| Empiric antimicrobial therapy is reasonable in patients who likely have infection as a cause of postoperative fever. In these cases, treatment should provide coverage for the most likely pathogen(s) based on the site of suspected infection and be administered after cultures are sent, if possible. Continuation or cessation of antimicrobial therapy should be tailored to culture results, if available, and whether there was a response to therapy. |
| Specific treatment |
| Source control of infection (eg, abscess drainage, removal of catheters). |
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