Open any surgical textbook or ask most surgeons and you will find that fever within the first 3 or 4 days after any major operation will most commonly be ascribed to atelectasis [the partial collapse of one or both lungs, usually due to pain-induced hypoventilation].
Some authors have questioned this dogma and now a systematic literature review published ahead of print in the journal, Chest, confirms that atelectasis and fever are not associated.
The authors reviewed well over 300 papers and found 8 which addressed the issue. Nearly 1000 patients were included. Of the 8 papers, 7 reported no link between the presence of fever and atelectasis. Due to heterogeneity of the studies, a formal meta-analysis could not be done.
The authors stated, “In conclusion, there is no clinical evidence suggesting that atelectasis is a major cause of EPF [early postoperative fever]. The rather limited evidence implies that atelectasis may be not associated with fever at all.”
Fever in the early postoperative period is likely due to an inflammatory response generated by the stress and trauma of surgery and anesthesia. It is a benign, self-limiting phenomenon and does not require intervention.
Like many long-held ideas, the belief that “atelectasis causes fever” will be difficult to change. I asked the authors what measures could be taken to enhance the awareness of surgeons about this important subject. The senior author, George C. Velmahos, MD, PhD, MSEd and John F. Burke Professor of Surgery at Harvard Medical School, feels that change might be prompted by “…by giving lectures and maybe designing a prospective multi-center study.”
Meanwhile, we will spread the word one blog reader at a time.
5 comments:
I look forward to getting pimped on this during my upcoming surgery clerkship. Should I say atelectasis and please the attending, or should I reference this article? What would you rather have a third-year clerk say?
Sorry for the delay in responding. Here is what I would say.
Many people believe and textbooks say that atelectasis is the most common cause of early postop fever. Recent research [see Chest article cited above & this article http://www.ncbi.nlm.nih.gov/pubmed/19667898] shows that atelectasis is probably not a cause of postop fever or even any fever at all. More likely early postop fever is caused by a measurable inflammatory response after the trauma of anesthesia and surgery.
I hope this helps. Let me know if the answer works. Good luck.
I'll give that a shot when the time comes, and I'll let you know.
Although atelectasis may not "cause" early post operative fever, I think it still wise to associate the two. If the early post op fever is not ascribed to atelectasis think of how many useless workups for pnuemonia will be undertaken after reviewing post op cxr read as pna vs. atelectasis. It seems to make more sense that fever post op would be caused by increased inflammatory metabolism rather than a random closing of alveoli, but by associating the fever with something that doesn't warrant an expensive work up, a costly goose chase is avoided. just my two cents on the matter
Anonymous,
Thanks for commenting. I believe the best option would be to stop ordering chest x-rays for patients with fever in the early postoperative period.
Post a Comment
Note: Only a member of this blog may post a comment.