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Difficulty: MediumPreoperative and Postoperative Care

During afternoon rounds, a physician evaluates a 54-year-old female patient due to an episode of elevated temperature. The patient underwent an uncomplicated laparoscopic cholecystectomy three days ago for recurrent biliary colic. She has been tolerating a regular diet and her pain is well controlled with oral medications. Her current vital signs show a temperature of 38.3°C (100.9°F), heart rate of 92/min, blood pressure of 128/82 mmHg, and respiratory rate of 14/min. Auscultation of the lungs reveals clear breath sounds bilaterally. Her abdomen is soft and non-tender, and the surgical port sites are healing appropriately without signs of infection. Inspection of the right distal forearm, where a peripheral venous catheter has been in place since admission, demonstrates localized tenderness, induration, and a 3-centimeter streak of erythema tracing the course of the vein. There is no fluctuance or purulent discharge. Which of the following is the most appropriate next step in management?

  1. Remove the peripheral venous catheterAnswer
  2. B
    Initiate empiric intravenous vancomycin therapy
  3. C
    Obtain a lower extremity venous duplex ultrasound
  4. D
    Administer a therapeutic dose of enoxaparin
  5. E
    Perform a computed tomography scan of the abdomen and pelvis

Answer

The most appropriate next step is to remove the peripheral venous catheter.
The correct answer is to remove the peripheral venous catheter. This patient is presenting with a low-grade fever and localized signs of inflammation (erythema, induration, tenderness) along the course of a vein hosting a peripheral IV catheter. This is the classic presentation of superficial infusion thrombophlebitis, a frequent cause of fever in hospitalized surgical patients (often categorized under 'Wires' or 'Wonder drugs/Wounds' in postoperative fever mnemonics). The initial and most definitive management is the prompt removal of the offending catheter. Warm compresses and nonsteroidal anti-inflammatory drugs (NSAIDs) can be added for symptomatic relief. Systemic antibiotics are not required unless there is evidence of frank purulence (suppurative phlebitis) or signs of systemic sepsis.

Step-by-Step Solution

1
Evaluate the timeline and clinical signs of the postoperative fever.
The patient developed a fever on postoperative day 3 with an identified local inflammatory reaction (erythema, induration, tenderness) at the site of an existing peripheral IV line.
Identifying the '5 Ws' of postoperative fever (Wind, Water, Wound, Walking, Wires) helps isolate the etiology. Here, the 'Wires' (IV catheter) is the likely culprit.
2
Diagnose the specific condition based on physical findings.
The 3-centimeter linear streak of erythema and induration indicates superficial infusion thrombophlebitis.
Phlebitis is a common complication of indwelling peripheral venous catheters left in place for multiple days.
3
Determine the standard of care for superficial infusion thrombophlebitis.
The definitive management is immediate removal of the catheter.
Source control is the primary intervention. Antibiotics are generally reserved for cases with suspected systemic bloodstream infection or frank purulence.

Key Concept

Superficial infusion thrombophlebitis is a common cause of postoperative fever that presents with erythema, tenderness, and a palpable cord at an IV site. The primary treatment is removal of the catheter.
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Topics

Preoperative and Postoperative Care

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