SLR - December 2017 - Elizabeth F. Neubauer

Post-Operative Fever in Orthopaedic Surgery: How Effective Is the "Fever Workup?"

Reference: Ashley B, Spiegel DA, Cahill P, Talwar D, Baldwin KD. Post-Operative Fever in Orthopaedic Surgery: How Effective is The ‘Fever Workup?’ J Orthop Surg (Hong Kong). 2017 Sep–Dec;25(3)

Scientific Literature Review

Reviewed By: Elizabeth F. Neubauer, DPM
Residency Program: Regions Hospital/HealthPartners Institute for Education and Research, Saint Paul, MN

Podiatric Relevance: Pyrexia in the early postoperative period is common following orthopaedic surgery and often prompts work-up for fear of atelectasis, deep vein thrombosis/pulmonary embolism or infection. The findings in this article are important in defining when a fever work-up provides necessary improvements in patient safety and when it may be an inappropriate use of resources. Researchers analyzed available literature to determine the frequency, timing and utility of chest x-rays, urine analyses, urine cultures and blood cultures. The data was correlated with the incidence of clinically significant infections to draw conclusions about the cost-effectiveness of the perioperative fever work-up.  

Methods: Two authors performed a comprehensive literature search for studies examining postoperative pyrexia following orthopaedic surgery. Subject headings included “postoperative fever/pyrexia” and “orthopaedic/orthopedic.” Studies were included if there were a minimum of five patients, patients required hospitalization postoperatively, patients were followed for a minimum of three days and were a level I-IV therapeutic or prognostic study design. A total of 22 papers were included. Examiners recorded percentages and proportions of patients with postoperative fever who received each component of the postoperative workup (blood culture, urine culture, urine analysis, chest x-ray, wound culture).

Results: The prevalence of postoperative pyrexia was 8.1–87.3 percent (adjusted 40.9 percent). Diagnostic yields of the aforementioned outcome measures are as follows: chest x-ray 0–40 percent (0.3 percent adjusted), urine analysis 8.2–38.7 percent (28.5 percent adjusted), urine culture 0–22.4 percent (10.9 percent adjusted) and blood culture 0–13.3 percent (3.5 percent adjusted). Twenty-four of 686 patients had positive blood cultures, two of the 24 had clinical sepsis, two were contaminants and one was on POD #16. The cost associated with each fever evaluation was $350 to $950.

Conclusions: Postoperative pyrexia is a very common event (50–87 percent) and is likely due to the inflammatory cascade initiated by surgery, the physiologic stress of surgery, deep vein thrombosis, phlebitis, atelectasis or anemia. Extensive work-ups have been routine, even in asymptomatic patients. This increases hospital length of stay and healthcare-associated costs. This study deemed blood cultures not to be predictive of clinically significant short-term nor long-term sequelae following orthopaedic surgery. Chest x-rays are not warranted unless patients exhibit pulmonary symptoms. The only time it is efficacious to implement fever work-up is for febrile events occurring after POD #3, in patients undergoing revision total joint arthroplasty or for temperatures ≥102°F.

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