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428
M. V. Butchy et al.
• Describe a laparoscopic appendectomy.
– There are several different techniques for a laparo-
scopic appendectomy; most commonly performed is
the three-port appendectomy (one camera port and two
“working” ports); however one-port appendectomies
have been described.
– Gain access to the abdomen through the umbilicus;
grasp both sides of the umbilicus with towel clips; lift;
make a small defect in the base of the umbilicus using
an 11 blade.
– Use a Schnidt forceps to open the umbilical ring defect
and place 5 or 12mm trocar in the defect and insufate
the abdomen. Place 5mm port in LLQ and 5mm port
above the pubic symphysis taking care to avoid the
bladder.
– Place table in Trendelenburg with patient’s right side
up.
– Identify the appendix and cecum. If the appendix is
retrocecal, mobilize the colon.
– Develop a window between the base of the appendix
and mesoappendix.
– Transect the appendix and the mesoappendix at the
base using a stapler or an endoloop.
– Place appendix in endoscopic retrieval pouch and
remove through the umbilicus or LLQ port.
– Inspect mesoappendix for signs of bleeding; irrigate
and inspect the abdomen for hemostasis.
• Describe an open appendectomy.
– Make RLQ incision. Over McBurney point (also could
be the point of maximal tenderness, paramedian or
lower midline).
– Create a muscle-splitting incision—divide muscle par-
allel to bers.
– Pull the cecum; deliver the appendix into the wound.
– Carefully divide and ligate the appendiceal mesentery
at the base of the appendix.
– Crush the appendix and ligate the proximal edge of the
crushed appendix.
– Place a purse string/Z-stitch the wall of the cecum at
the base of the appendix; wait to tie it. Transect the
appendix able the ligature and remove, tying down the
purse string/Z stitch.
– Close incision in three layers, peritoneum/transversalis
fascia, internal oblique, and then external oblique.
• What are some common complications?
– Pelvic abscess
– Stump leak
– Dropped or loss fecalith
– Bowel obstruction
– Bowel/bladder/vascular injury from trocar
Perforated Appendicitis
Alternate Scenario
“A 10-year-old boy is transferred to your ED after presenting
with 2–3 days of fever, RLQ abdominal pain, nausea, and
vomiting. The mom reports that the patient has been feeling
unwell for 2–3 days. CT acquired at the outside hospital
emergency department shows a dilated and uid-lled
appendix with surrounding tissue stranding, free uid in the
pelvis, and suspected perforation.”
• How would you manage this patient differently?
– Patients that present with abscess can be difcult to
manage.
– Data favors early appendectomy compared to initial
antibiotics followed by interval appendectomy.
Patients with initial antibiotics had longer hospitalizations, higher hospitalization cost, and fewer adverse
events.
– It’s very reasonable to plan to take this patient with
signs of perforated appendicitis to the OR for a laparoscopic or open appendectomy.
– At the time of surgery, if it is not safe to remove the
appendix, then washing out the abdomen and draining
the collection is a reasonable option.
– Most important is to continue antibiotic therapy fol-
lowing surgery, typically monotherapy Zosyn or dual
therapy with ceftriaxone and metronidazole.
Perforated Appendicitis, Interval Appendectomy
Alternate Scenario
“A 10-year-old boy is transferred to your ED after presenting
with 1–2weeks of fever, abdominal pain, nausea, and vomiting. The mom reports that the patient has been feeling unwell
for 1–2 weeks. CT acquired at the outside hospital emergency department shows a dilated appendix with surrounding uid concerning for large walled-off abscess.”
• How would you manage this patient differently?
– Patients that present with clear abscess can be difcult
to manage. There is controversy in deciding whether to
manage nonoperatively with antibiotics, to place a CTguided drain, or to take the patient to the OR for appendectomy and washout. There is concern that in the
acute inammatory phase, surrounding structures may
be damaged in the process of resecting the appendix.
– Walled-off abscesses collected are generally managed
best with IR drainage and IV antibiotics.
124 Pediatric Appendicitis
429
• What is the appropriate length of time to interval
appendectomy?
– At an interval of 6–8weeks after initial presentation.
• Further recommendations
– In nonperforated appendicitis, there is no evidence that
suggests additional antibiotics (after initial dosing of
perioperative antibiotics) improve outcomes.
– Many children that undergo laparoscopic appendec-
tomy for nonperforated appendicitis go home the same
day of surgery.
• Long-term follow-up
– Routine follow-up is typically limited to one ofce
visit for a wound check.
Clean Kills
• Offering nonoperative management for a patient with
appendicolith
• Failure to initiate antibiotics for patient with perforated
appendicitis
• Failure to resuscitate a patient prior to the OR
• Continuing to pursue resection in a complicated perforated appendicitis when there is substantial inammation
• When operating, if there is creeping fat on the TI and it
looks abnormal, the patient may need a workup for
Crohn’s disease. Take the appendix if the base is not
inamed!! This removes the differential for the patient in
the long term.
Words ofWisdom
• Since this is the most common pediatric surgical procedure performed, we spend a lot of time discussing these
patients. In general, a simple appendicitis can be diagnosed without imaging, with a negative appendectomy
rate<5%. These patients only receive antibiotics preoperatively and go home following the procedure.
Complicated/perforated appendicitis practice varies, but
for shorter duration <5days without a contained abscess,
go to the operating room, and stay inpatient for 3 days for
IV antibiotics. At day 7, if they are still febrile or symptomatic, many surgeons would elect to reimage for
abscess. At this point, patients with new abscess go to IR
for drainage.
Bibliography
Bonus Points
• If the appendix looks normal, then you need to identify a
cause for the abdominal pain. Look for Meckel’s
diverticulitis!!
Holcom and Ashcraft’s Pediatric Surgery (7th ed.). Chapter 42.
Appendicitis. Hollwarth M. 2019.
Operative dictations in general and vascular surgery.
Townsend, J. C. M., Beauchamp, R. D., Evers, B. M., & Mattox, K. L.
(2016). Sabiston textbook of surgery (20th ed.). Elsevier - Health
Sciences Division.
www.surgicalcore.org. SCORE. Appendicitis. (Pediatric/Fellowship
Level) August 17, 2023.
Tracheoesophageal Fistula
AdamGoldsmith andErikaB.Lindholm
125
Concept
Inability to pass OG/NG tube with radiologic evidence of
coiled NG/OG tube on chest X-ray. Without gastric bubble
(isolated esophageal atresia). With gastric bubble (distal tracheal stula).
Tracheoesophageal Fistula
Scenario
Pediatric surgery is consulted for a healthy full-term newborn infant with excessive drooling and coughing during the
rst attempt to feed. The patient’s oxygen saturation was
noted to decrease while they attempted feeding. Due to
inability to feed, an OG tube was attempted but was unable
to be placed. CXR shows distal air within the intestine.
• How would you assess and diagnose your patient?
– First ensure the patient’s airway is secure. Elevate the
head of the bed to 30°.
– With known inability to place an NG or OG tube, the
next best step would be to get a CXR showing conrmation of the tube curled in the proximal esophagus.
Insufation through the OG at the time of CXR can
help show the proximal pouch.
If radiographic ndings are equivocal, a contrast
esophagram may be performed though it carries
increased aspiration risk.
– CT is not routinely recommended due to increased
radiation risk.
• What time of TEF does this patient have?
A. Goldsmith
Cooper Medical School of Rowan University, Camden, NJ, USA
E. B. Lindholm (
Division of Pediatric Surgery, Children’s Regional Hospital,
Cooper University, Camden, NJ, USA
e-mail: Lindholm-Erika@cooperhealth.edu
*)
– Both type A and B will present with a gasless abdomen
due to lack of distal stula. The presence of gas means
that it is most likely a type C but could be the much
rarer type D.Many surgeons prefer to perform bronchoscopy in the OR to check for a more proximal double stula.
• Does the patient need any additional studies?
– Due to association with VACTERL, these patients
should undergo careful physical exam as well as full
cardiac and genitourinary workup to identify any other
associated malformations.
– ECHO is critical to assess for additional abnormalities,
including aortic arch location. In patients with a rightsided arch, many surgeons would choose to perform a
left-sided thoracotomy for surgical repair.
• Describe the surgical repair options and considerations
regarding the timing of surgery
– Procedure may be done electively though often in the
rst few days of life in healthy patients weighing
>1.6kg.
– Extrapleural access is acquired via open right
thoracotomy.
– In the most common variant (type C), proximal esoph-
ageal blind pouch with distal TEF denitive treatment
is by stula division with tracheal repair and primary
anastomosis of the esophagus.
The stula will typically be located underneath the
azygos vein and can be identied after the vein is
ligated.
Typically, a vascular clip is placed over the stula
prior to ligating to ensure that the aorta or bronchus
is not mistaken for the stula.
– Circumferential dissection of the proximal pouch
allows it to be removed off the membranous portion of
the trachea, and subsequent tracheal repair with interrupted nonabsorbable sutures can follow.
– The proximal esophageal segment should be mobi-
lized rather than the distal segment due to its more
robust blood supply.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_125
431
432
A. Goldsmith and E. B. Lindholm
– The esophagus should be anastomosed with minimal
tension after the proximal and distal ends are prepared
with good perfusion.
– Chest tube is placed near the anastomosis to control
leak and prevent tension pneumothorax from
occurring.
• Postoperative management
– Patients typically remain NPO for 5–7 days when an
esophagram is performed to check for leak and stricture. If the esophagram is satisfactory, then the patient
is started on feeds and the CT is removed.
• What complications may arise?
– Leaks of the esophageal anastomosis occur in 15% of
patients. Leaks can be controlled or uncontrolled.
Patients with controlled leaks are managed by the
chest tube and remain stable. These leaks can be
monitored by repeat esophagrams until the leak has
sealed.
Uncontrolled leaks show extravasation into the
chest cavity. The patients can be quite sick.
Additional chest tubes may be placed to attempt to
control the leak. However, as last resort, these
patients may need to go back to the OR for
diversion.
– Anastomotic strictures are more common, occurring in
nearly 80% of patients. This can be managed with
serial dilation in the operating room.
– All patients will suffer from GERD and may be at
increased risk for Barrett esophagus and esophageal
cancer.
• What is the prognosis after surgery?
– Nearly 100% survival in patients without other severe
congenital abnormalities.
– The lowest survival rates are seen in patients with low
birth weight and/or severe cardiovascular
abnormalities.
Alternate Scenario
Pediatric surgery is consulted for a healthy full-term newborn infant with excessive drooling and coughing during the
rst attempt to feed. Due to inability to feed, an OG tube was
attempted but was unable to be placed. Follow-up chest
X-ray demonstrates curling of the OG tube in the proximal
esophagus without any distal gas.
– These patients will still go to the OR for placement of
a gastrostomy tube so that the child can have enteral
nutrition. At this time, a bougie is placed through the
mouth into the proximal pouch, and a probe from the
gastrostomy into the distal pouch can measure the
length of the gap on XR.Patients with a gap >3 vertebrae are termed “long-gap” and require different treatment as it is unsafe to repair the esophagus at this time.
• What are the important considerations for treating this
child?
– Proximal blind pouch decompression with an indwell-
ing Replogle to prevent aspiration of oral secretions.
– Feeding access via gastrostomy because as the child
grows the pouches will actually get longer and closer
together. This is the most traditional approach to repair.
Monthly measurements of the gap length until the gap
gets small enough for surgical repair.
– Lengthening
This remains a challenging area with many options.
Large bolus gastric feeds are often utilized to maximize growth of the distal esophageal pouch.
External traction sutures can be placed to more rapidly pull the pouches together—the Foker process.
If more length is required, primary intrathoracic
segmental esophageal replacement via colonic segment can typically be performed between 4 and
6months.
Other rare options are gastric tube pull-up and small
intestinal free microvascular graft.
Clean Kills
• Taking a newborn to the OR without ECHO evaluation.
Cardiac anomalies are part of the VACTERL association.
• Bringing the baby back to the OR in a controlled anastomotic leak. Wait it out—can continue for weeks.
• Failing to properly identify the stula and ligating the
wrong structure. After you place the vascular clamp,
watch the pressures remain stable and the lung continues
to inate.
Bonus Points
• What is different in this case?
– The lack of distal bowel gas indicates the lack of distal
tracheal stula, so it would have to be a type A or B
stula. Both are rare, but more common to be a pure
esophageal atresia (type A) which means there is a
long gap which is not amenable to immediate
surgery.
• How is the management different?
• Remember the dangerous condition here is the stula.
The goal of surgery is ligation of the stula to prevent
airway complications. In premature babies <1.6kg, the
safest approach is to ligate the stula and come back for
denitive repair when it is >2kg.
• TEF can be found in combination with other conditions—
most commonly duodenal atresia and anorectal malformations. When discussing the order of repair, most
125 Tracheoesophageal Fistula
433
important is ligation of the stula for safety; then you
must repair the distal obstruction prior to xing the
esophageal atresia. In some cases, you can repair everything in the same OR visit, but if not ligate the stula, x
the obstruction, and potentially provide some feeding
access.
Words ofWisdom
• The key to a safe surgery is ensuring that the proper
workup has been performed. Parents should be made
aware of the postoperative complications and how they
are managed. Setting the correct expectations for recovery is key. I always discuss the need for long-term PPI and
that the patient will always have some element of reux
due to the abnormal anatomy of the stomach and
esophagus.
Bibliography
www.surgicalcore.org. SCORE. Esophageal Atresia and
Tracheoesophageal Fistula. (Pediatric/Fellowship Level) August
17, 2023.
Townsend, J. C. M., Beauchamp, R. D., Evers, B. M., & Mattox, K. L.
(2016). Sabiston textbook of surgery (20th ed.). Elsevier - Health
Sciences Division.
Part XVII
Perioperative Care
Postoperative Hypotension
JoelB.Durinka andJoshuaA.Marks
126
Postoperative Hypotension
Hypotension in the postoperative patient can be due to serious causes such as bleeding, sepsis, adrenal insufciency, or
cardiac causes. It is important to diagnose and treat these
conditions, since their progression can result in shock, multiorgan failure, and death.
Once these life-threatening causes are ruled out, other
more common causes such as hypovolemia due to insensible
losses during the case or reactions to certain drugs, especially narcotics, sedatives, and epidural regional anesthesia,
should be considered.
• Postoperative bleeding is usually due to incomplete
hemostasis during the operation or coagulopathy, which
can be seen after severe trauma or in liver failure. It is
imperative to rule out bleeding as the cause of hypotension in the immediate postoperative period since it may
require a return to the operating room.
• Sepsis can cause distributive shock due to a massive
inammatory response to infection. Usually the infection
is bacterial, although fungi, viruses, and parasites can also
cause sepsis. The inammatory cascade that occurs causes
vasodilation and increased capillary permeability, resulting in hypotension due to decreased circulatory volume.
• Adrenal insufciency can result in systemic hypotension
due to low levels of glucocorticoids, which are necessary
for adequate systemic vascular resistance (SVR). Adrenal
insufciency can be primary (Addison’s disease) or secondary as a result of suppression of the hypothalamicpituitary- adrenal (HPA) axis. In either case, any stress on
the body, such as with surgery, trauma, or major illness,
will require additional glucocorticoid to maintain SVR
and blood pressure. However, patients with adrenal insuf-
J. B. Durinka · J. A. Marks (*)
Division of Acute Care Surgery, Department of Surgery, Thomas
Jefferson University, Philadelphia, PA, USA
e-mail: Joel.Durinka@jefferson.edu; joshua.marks@jefferson.edu
ciency will be unable to endogenously produce this
additional steroid, and can present with refractory hypotension postoperatively. The HPA axis will be iatrogenically suppressed in patients that are on steroids for
medical conditions (COPD, rheumatoid arthritis), and it
is important to recognize that refractory hypotension in
these patients may be due to adrenal insufciency. Adrenal
suppression is a commonly tested side effect in patients
receiving etomidate, a sedative used for induction of anesthesia. This is rarely seen as it typically only occurs with
continuous etomidate infusions, which are no longer
done.
• Cardiac causes of postoperative hypotension include
acute myocardial infarction (MI) from coronary artery
plaque rupture resulting in left ventricular (LV) dysfunction, exacerbation of congestive heart failure (CHF), or
arrhythmias. Atrial brillation with rapid ventricular
response (RVR) occurs frequently after surgery due to
uid shifts and electrolyte imbalances and can result in
hypotension due to decreased lling time of the LV and
decreased preload. Preoperative cardiac assessment,
which may involve stress testing, should be done for
patients with cardiac risk factors to evaluate their risk of
perioperative cardiac complications, and coronary revascularization may be needed to decrease risk prior to elective noncardiac surgery.
Way Question May BeAsked?
A 54-year-old man with a non-obstructing colon adenocarcinoma presents for colectomy. He has a history of
hypertension and coronary artery disease, and he had a
coronary artery bypass graft 2years ago. He walks his
dogs most days around the block and hikes 2–3miles on
weekends. The patient underwent a successful robotic
low anterior resection with primary anastomosis. The
procedure was uncomplicated. About 30min after being
brought to the postanesthesia care unit (PACU), the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_126
437
438
J. B. Durinka and J. A. Marks
patient becomes hypotensive to the 70s systolic and
tachycardic to the 140s. Also, the patient has not made
any urine since he arrived in the postanesthesia care unit
(PACU).
Way toAnswer?
• Examine the patient. Is the abdomen distended? Does he
have any drains that might be sanguinous? What is his
temperature?
• Begin volume resuscitation (ensure appropriate venous
access)—initial limited crystalloid followed by early
blood transfusion, especially, if bleeding is suspected.
• Check STAT CBC/hemoglobin—recognize however that
hemoglobin is not an acute phase reactant and may not
immediately reect the fact that the patient is bleeding.
– Other labs of interest: lactate, coagulation parameters
(platelet count, INR, thromboelastography (TEG)).
• EKG for tachycardia—assess for regularity, atrial brillation, and/or ST segment changes.
• Prompt return to operating room for exploration and hemorrhage control.
• Consider transfer to higher level of care postoperatively.
• Monitor hemodynamics, urine output, and other endpoints of resuscitation.
• Once stabilized, halt active resuscitation and evaluate for
appropriateness of diuresis.
Way toAnswer?
• Assess hemodynamics and observe postoperative trend.
• Review labs.
• Start resuscitation. Ensure adequate IV access and monitoring. Consider vasopressor support.
• Check an EKG and draw cardiac enzymes.
– EKG shows Ab—what do you do?
Attempt to rate control to increase lling time vs
synchronized cardioversion since the patient is
unstable.
– EKG shows ST segment elevations in leads II, III, and
aVF—what do you do?
STAT cardiology consult for cardiac
catheterization.
Is it OK to heparinize and/or place on antiplatelet
therapy?
Bonus Points
Patients taking chronic steroids should receive stress dose
steroids prior to surgery and general anesthesia. Typically
less than the equivalent of 20mg of prednisone daily does
not derive benet from stress dose steroids.
Words ofWisdom
Alternative Scenario
A 58-year-old man with a non-obstructing colon adenocarcinoma presents for colectomy. He has a history of hypertension, hyperlipidemia, and obesity. He walks his dogs most
days around the block. The patient underwent a laparoscopic
right hemicolectomy with primary anastomosis. The procedure was uncomplicated. About 60min after being brought
to the PACU, the patient becomes hypotensive to the 60s systolic and tachycardic to the 140s. He is lethargic and complains of chest discomfort. A CBC drawn on arrival in PACU
comes back as 10.5 from 11 pre-op.
Acute postoperative hypotension is caused by bleeding until
proven otherwise. Always maintain a high index of suspicion
for bleeding. While taking a patient back to the OR is a challenging decision, it is almost never the wrong decision.
Bibliography
SCORE. https://surgicalcore.org.
Townsend CM, etal., editors. Sabiston textbook of surgery: the biologi-
cal basis of modern surgical practice. 21st ed. St. Louis: Elsevier;
2022.
Postoperative Fever
QuinnMurray andJoshuaA.Marks
127
Way Question May BeAsked?
Scenario 1
A 52-year-old man with a history of hypertension wellcontrolled on amlodipine presents for an elective left inguinal hernia repair with mesh under general anesthesia. The
case was overall uncomplicated, estimated blood loss was
less than 15 mL, and he awakened in the PACU uneventfully.
Prior to moving to phase 2, his temperature was recorded at
100.7°F.Heart rate remains in the mid 80s, he remains normotensive, and respiratory rate is within normal limits and
unlabored. He reports that he was asymptomatic aside from
feeling groggy from anesthesia and now feels more so back
to baseline.
How toAnswer?
• As always, start with a history and physical exam.
• This is a patient presenting with immediate postoperative
fever without any truly concerning signs to back up a
pathologic diagnosis requiring broad workup. Without
any other changes in vital signs or symptoms, and without
clear deviations from the operative course, this is a postoperative fever of likely little consequence and can be
observed.
• One consideration that may be worth asking which is not
included in the stem might be to ask “Has the patient
voided urine postoperatively?” or “Has he required catheterization?” These inclusions may be hints of something
more worthy of investigation, but nonetheless it would be
unlikely to manifest as a fever this quickly.
• Atelectasis is classically considered the overall most
common noninfectious cause of postoperative fever.
Some sources question the pyrogenicity of atelectasis
Q. Murray · J. A. Marks (*)
Division of Acute Care Surgery, Department of Surgery, Thomas
Jefferson University, Philadelphia, PA, USA
e-mail: joshua.marks@jefferson.edu
alone, however, and suggest looking for other causes to
which to attribute a fever. Pneumonia may also occur in a
similar timeframe and should be considered if chest
radiograph shows an inltrate.
– Atelectasis is more common in the immediate and
early postoperative course. However, conditions that
restrict mobility, or inadequate pain control, may precipitate it outside of the early period.
– Atelectasis is a partial or complete collapse of alveoli,
and can present with hypoxia, tachypnea, and reduced
breath sounds, or may be asymptomatic.
– Atelectasis can be reversed within 24–48 h with early
mobilization, regular incentive spirometer use, and
chest physiotherapy, optimizing pain control; conversely it may progress to pneumonia and cause further decompensation if not addressed with the therapies
listed.
• SIRS (Systemic Inammatory Response Syndrome)
and non-infectious causes
– SIRS is dened by two or more of the following: tem-
perature greater than 36°C (96.8°F), heart rate greater
than 90 bpm, respiratory rate greater than 20/min or
PaCO2 less than 32 mmHg, and WBC either greater
than 12,000 or less than 4000 with greater than 10%
bands (Abdelmaseeh etal. 2023).
SIRS can be precipitated by direct trauma to tissues
during surgery and is very common within the rst
48 h postoperatively, but as time progresses the etiology of SIRS must include a broadened differential and stronger consideration of infectious
etiologies.
Tissue trauma causes a release of the pyogenic
cytokine IL-1, levels of which correlate with a proportional increase in temperature.
Other cytokines including TNF-α, IL-6, and INF-γ
are released in response to inammation and contribute to the changes seen in temperature regulation, heart rate, and laboratory abnormalities
associated with SIRS.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_127
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Q. Murray and J. A. Marks
Many electronic medical record systems utilize
SIRS criteria to alert clinicians to potential clinical
problems and/or deterioration. Would be sepsis
sniffers and clinical deterioration scores are notoriously overly sensitive in the surgical population and
caution should be used in interpreting these results.
One must always look to the patient directly and
assess.
• Venous thromboembolism is a proposed “never event”
and appropriate prophylaxis should be ordered to help
prevent it. Deep venous thrombosis (DVT) may cause
fever due to clot burden and endothelial lining inammation and/or injury. DVT is most likely to occur 2–10 days
after surgery; however, the risk remains elevated for up to
a month postoperatively.
– Important considerations for this complication are
type of surgery and duration of immobilization (orthopedic surgery, particularly spine procedures), presence
or lack of perioperative DVT prophylaxis, and any
missed or held doses.
– Physical exam may reveal unilateral leg swelling, ery-
thema, and calf tenderness, or it may be masked by
edema or other patient-specic exam ndings.
– Pulmonary embolism (PE) generally occurs later but
has an overlapping timeframe with DVT, and concerning signs may include tachycardia, tachypnea, hypoxia,
chest pain, and evidence of right heart strain on EKG
and/or echocardiogram.
– Lower extremity duplex ultrasound is generally the
most reliable diagnostic tool for lower extremity DVT,
and CT angiogram PE protocol of the chest is necessary if concern for PE exists.
– Treatment is with systemic anticoagulation, or IVC l-
ter if anticoagulation is contraindicated. Thrombolytics
or thrombectomy in PE with hemodynamic compromise can be considered.
• Wound infection is more likely to manifest as fever
around postoperative day 5–10. Wound or surgical site
infections are classied as supercial, deep incisional,
and organ space.
– A supercial incisional surgical site infection occurs
within the rst 30 days and includes at least one of the
following: purulent drainage, organisms isolated from
aseptically obtained culture of uid, pain, erythema, or
swelling.
– Common causative organisms are Staphylococcus
aureus and other staph species, Streptococcus species,
Enterococcus species, Escherichia coli, Enterobacter
species, and Pseudomonas aeruginosa. Abdominal
infections are more likely related to gram-negative
bacilli and anaerobes. Diabetics are more likely to
have polymicrobial wounds.
– Prevention includes skin prep with alcohol-based anti-
septic, glycemic control for blood glucose <200 mg/
dL, perioperative normothermia, and, if hair must be
trimmed, using a clipper, and a not razor.
– Treatment includes opening wounds to allow infected
uid to drain. Antibiotics may not be necessary unless
systemic signs of infection, such as tachycardia, leukocytosis >12,000, or erythema further than 5cm from
wound edges, are present.
– If antibiotics are to be used, cultures should be obtained
to tailor treatment appropriately.
– A deep surgical site infection, including abscess,
infected hematoma, or seroma, requires drainage or, in
rare cases, re-exploration, for source control.
• Central line-associated bloodstream infections
(CLABSI) are the most common source of nosocomial bacteremia and septicemia and one of the proposed “never events” that are avoidable with
appropriate indication, care, maintenance, and timely
removal. Early diagnosis is critical to reduce morbidity and mortality. Organisms include staphylococci
(both S. aureus and coagulase- negative staphylococci),
enterococci, aerobic gram- negative bacilli, and fungal
species (e.g., Candida albicans). Diagnosis requires
positive peripheral blood culture with no apparent
source besides the catheter, and clinical evidence of
infection (fever, chills, hypotension). Treatment is
with removal of catheter and antibiotics, generally
empiric pending cultures, including vancomycin for
MRSA coverage.
• Urinary tract infection is another common infectious
cause of postoperative fever.
– More common in patients with pre-existing prostate
hypertrophy.
– Catheterization and other bladder instrumentation of
any kind during the perioperative period are recognized risk factors. A catheter-associated urinary tract
infection (CAUTI) is another largely preventable entity
with appropriate use, maintenance, and timely
discontinuation.
– Foley catheters should always be removed as soon as it
is feasible to do so. Catheters should not be left in
unnecessarily.
– A urinalysis and urine culture are diagnostic tools.
Antibiotics should be tailored to the classication of
the condition as complicated or uncomplicated,
catheter- associated or not, and hospital-acquired or
not. The duration should be evidence based and deescalated as more data is available.
• Drugs can be a source of fever if all other etiologies have
been ruled out.
– This, like central fevers, is a diagnosis of exclusion.
– Signs may include peripheral eosinophilia, rash, and/
or hives.
– Typical culprits are various antibiotics.