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Difficulty: MediumPreoperative and Postoperative Care

During routine evening rounds, a physician is asked to assess a patient who recently underwent abdominal surgery. The patient is a 54-year-old male who had an open partial colectomy for a large, benign colonic polyp 48 hours ago. The nursing staff reports that his temperature has increased to 38.5°C (101.3°F). Vital signs show a blood pressure of 130/80 mmHg, pulse of 96/min, and respirations of 20/min. Oxygen saturation is 96% on room air. The patient feels slightly fatigued but denies any chest pain, shortness of breath, or pain with urination. He is currently receiving patient-controlled intravenous morphine. On physical examination, the abdomen is mildly distended with hypoactive bowel sounds, and the surgical dressing is clean and dry. Auscultation of the chest reveals diminished breath sounds bilaterally at the lung bases without crackles or wheezes. There is no calf swelling or tenderness. Which of the following is the most appropriate initial intervention for this patient?

  1. Encourage frequent deep breathing exercises and coughingAnswer
  2. B
    Begin empirical therapy with broad-spectrum intravenous antibiotics
  3. C
    Administer a dose of intravenous furosemide
  4. D
    Remove the surgical staples to evaluate for deep fascial dehiscence
  5. E
    Prepare the patient for an urgent exploratory laparotomy

Answer

Encourage frequent deep breathing exercises and coughing
The correct response is to encourage frequent deep breathing exercises and coughing. This patient presents with a fever on postoperative day 2 alongside diminished breath sounds at the lung bases, which strongly suggests atelectasis. After abdominal or thoracic surgery, incisional pain often causes patients to take shallow breaths, leading to the collapse of dependent alveoli. This alveolar collapse triggers localized inflammation and the release of cytokines, which can cause a low-grade fever. Management consists of adequate pain control and pulmonary toilet strategies, such as incentive spirometry, deep breathing, and coughing exercises, which mechanically re-expand the collapsed lung segments.

Step-by-Step Solution

1
Analyze the timing of the patient's fever.
The patient developed a fever 48 hours (postoperative day 2) after an open abdominal surgery.
The timing of postoperative fever is the most reliable clue for determining its etiology. Fevers within the first 48-72 hours are generally non-infectious.
2
Evaluate the clinical findings and physical examination.
The patient has diminished breath sounds at the lung bases but no signs of wound infection, DVT, or UTI.
Pain from an abdominal incision often leads to shallow breathing, which causes dependent airways to collapse (atelectasis), presenting as diminished breath sounds.
3
Determine the best initial intervention based on the suspected diagnosis of atelectasis.
The correct intervention focuses on alveolar recruitment and lung expansion.
Deep breathing exercises, incentive spirometry, and early ambulation effectively reverse atelectasis and the associated inflammatory response.

Key Concept

Postoperative fever occurring within the first 48 to 72 hours is most commonly caused by tissue trauma (cytokine release) or atelectasis, and is managed supportively with lung expansion maneuvers rather than antibiotics.
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Topics

Preoperative and Postoperative Care

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