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Difficulty: EasyPreoperative and Postoperative Care

A 58-year-old man is evaluated on postoperative day 1 following an elective open right hemicolectomy for early-stage colon cancer. He reports mild to moderate pain at the surgical site, which is adequately controlled with intravenous analgesics. His temperature is 38.3°C (101°F), blood pressure is 128/78 mmHg, pulse is 88/min, and respirations are 16/min. Pulse oximetry shows 95% on room air. Physical examination reveals decreased breath sounds at both lung bases. The surgical incision is clean, dry, and intact with no erythema or induration. The urinary catheter was removed earlier today, and he has voided spontaneously. Which of the following is the most appropriate next step in management?

  1. Encourage incentive spirometry and early ambulationAnswer
  2. B
    Order a chest radiograph and start intravenous broad-spectrum antibiotics
  3. C
    Obtain a urinalysis and urine culture
  4. D
    Remove the surgical staples and probe the wound
  5. E
    Initiate therapeutic anticoagulation with enoxaparin

Answer

The most appropriate next step is to encourage incentive spirometry and early ambulation.
Fever within the first 48 hours (postoperative days 1 and 2) is incredibly common and is most often a non-infectious response mediated by inflammatory cytokines (e.g., IL-1, IL-6, TNF-alpha) released due to tissue trauma. It is frequently associated with atelectasis, which is supported by the physical examination finding of decreased breath sounds at the lung bases. The standard initial management for atelectasis and early, non-infectious postoperative fever is supportive care, specifically incentive spirometry, deep breathing exercises, coughing, and early ambulation. These measures open collapsed alveoli and aid in clearing airway secretions.

Step-by-Step Solution

1
Analyze the timing of the patient's fever.
The fever is occurring on postoperative day 1.
Postoperative fever etiologies strongly correlate with the number of days since surgery.
2
Correlate the timing with physical examination findings.
Decreased breath sounds at the bases with no focal infectious signs (e.g., clear wound, no UTI symptoms).
Decreased breath sounds on day 1 strongly suggest atelectasis, a common cause of early postoperative fever driven by inflammatory cytokines.
3
Determine the appropriate management.
Select supportive care aimed at lung expansion.
Atelectasis is managed supportively with deep breathing exercises, incentive spirometry, and early ambulation.

Key Concept

Postoperative Fever Timeline and Management
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Topics

Preoperative and Postoperative Care

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