Post-operative fever in orthopaedic surgery: How effective is the ‘fever workup?’

Abstract

Background: Defining the appropriate threshold at which to initiate a fever workup is imperative to promote patient safety, appropriate resource utilization, and antibiotic stewardship. Our group performed a systematic review of the available literature on perioperative fever (POF) workups in orthopaedic patients to evaluate the frequency, timing and utility of blood cultures (BC) and other investigations in the POF workup, to determine the clinical relevance of any infections and to evaluate their cost effectiveness. Methods: Studies were identified by searching MEDLINE, EMBASE, Pubmed, Cochrane and Google Scholar for articles through September 2016. Forty-nine articles were retrieved and 22 articles met the pre-determined inclusion criteria. Proportions of positive studies were noted and averaged using random effects analysis. Results: Post-operative pyrexia ranged in prevalence between 8.1% and 87.3%. The studies routinely performed during a fever workup had wide ranges of diagnostic yield, including chest X-rays from 0% to 40%, urinalyses from 8.2% to 38.7%, urine cultures from 0% to 22.4% and BC from 0% to 13.3%. Only two patients with positive BC developed clinical sepsis. Cost per fever evaluation ranged from $350 to $950. Conclusion: The findings of this review suggest that early post-operative fever is an expected event following orthopaedic surgery. Based on the available literature, any kind of workup in the absence of localizing symptoms in the third post-operative day or before is unwarranted and is an inappropriate use of hospital resources.

A Randomized Study on The Prophylactic Use of Acetaminophen to Prevent Fever After The Removal of Drainage Tubes in Lumbar Surgery

“…Fortunately, almost all the patients' temperatures gradually became normal after observation or antipyretic treatments before discharge. Similar to the reports of many previous studies, the evaluation of fever was costly, time consuming, and painful for patients and could add medical expenditure, prolong the hospital stay and waste health care resources [3,4,[8][9][10].…”

Reduction in the Duration of Postoperative Fever during the COVID-19 Pandemic in Orthopedic and Traumatic Surgery Due to PPE and Cautions

“…Early postoperative fever is a common event and is infrequently associated with infection [ 5 ]. Literature suggests that any kind of workup in the absence of localizing symptoms in the third post-operative day or before is unwarranted and is an inappropriate use of hospital resources [ 6 ].…”

“…Indeed fever, even up to the seventh postoperative day, is not substantially helpful to distinguish infection from general inflammation in clean orthopedic surgery [ 7 ]. Under the third post-operative day, patients who experienced multiple febrile episodes, or temperatures over 38.5 °C or who underwent revision surgery are at the greatest risk of having an underlying infection [ 6 ].…”

Post-operative Management

“…Studies agree that investigations, particularly chest X-rays or blood and urine cultures, performed to study early post-operative febrile episodes without clinical symptoms or signs of infections are rarely positive and are therefore an inappropriate use of hospital resources [65]. On the other hand, patients with hip fracture with a high degree of frailty, malnutrition, multiple comorbidities, polypharmacy, may have a compromised immune response that predisposes to infection.…”