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Difficulty: EasyPreoperative and Postoperative Care

A 68-year-old man is evaluated on postoperative day 2 after undergoing an elective right total hip arthroplasty for severe osteoarthritis. His medical history includes hypertension and diet-controlled type 2 diabetes mellitus. His temperature is 38.1∘C38.1^\circ\text{C} (100.6∘F100.6^\circ\text{F}), blood pressure is 135/85 mmHg135/85\text{ mmHg}, pulse is 88/min88\text{/min}, and respiratory rate is 16/min16\text{/min}. Oxygen saturation is 94%94\% on room air. The patient reports mild incisional pain that is well-controlled with oral analgesics, but denies chest pain, shortness of breath, dysuria, or leg pain. Physical examination reveals decreased breath sounds and fine crackles at the bilateral lung bases. The surgical incision is clean, dry, and intact with no surrounding erythema or discharge. The bilateral calves are non-tender and without swelling. Based on the most likely diagnosis, which of the following are the most appropriate next steps in management? (Select all that apply)

  1. Prescribe incentive spirometry and targeted deep breathing exercisesAnswer
  2. Encourage out-of-bed activity and early ambulationAnswer
  3. C
    Administer intravenous furosemide
  4. D
    Initiate empiric intravenous vancomycin and piperacillin-tazobactam
  5. E
    Order a comprehensive lower extremity venous duplex ultrasound

Answer

The most appropriate next steps are prescribing incentive spirometry and encouraging early ambulation.
The patient is presenting with a low-grade fever and bibasilar crackles on postoperative day 2, which is the classic presentation for atelectasis (the 'Wind' in the '5 Ws' of postoperative fever). General anesthesia and incisional pain often lead to shallow breathing and decreased coughing, which causes small airway collapse. The standard, most appropriate management for postoperative atelectasis is supportive and relies on mechanical expansion of the lungs. The correct approaches include prescribing incentive spirometry to encourage deep inspirations, and promoting early ambulation, which increases respiratory drive and helps mobilize pulmonary secretions.

Step-by-Step Solution

1
Analyze the timing of the patient's postoperative fever.
The fever is occurring on postoperative day 2.
The '5 Ws' mnemonic helps categorize postoperative fever timing: Wind (Days 1-2), Water (Days 3-5), Walking (Days 4-6), Wound (Days 5-7), and Wonder drugs (Any time).
2
Correlate the timeline with the physical examination findings.
The patient has bibasilar fine crackles and decreased breath sounds.
These findings are classic for atelectasis, which is the most common cause of low-grade fever on postoperative days 1-2 due to shallow breathing and retained secretions.
3
Determine the appropriate management for early postoperative atelectasis.
Select non-pharmacologic respiratory interventions.
Atelectasis is managed and prevented by improving lung expansion and airway clearance through incentive spirometry, deep breathing exercises, and early ambulation.

Key Concept

Management of early postoperative atelectasis
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Topics

Preoperative and Postoperative Care

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