수술 후 발열


목차

수술 후 발열의 원인

감염성 원인 vs. 비감염성 원인

감염성 원인

비감염성 원인

  • Abscess 
  • Acalculous cholecystitis
  • Bacteremia
  • Decubitus ulcers
  • Device-related infections
  • Empyema 
  • Endocarditis 
  • Fungal sepsis
  • Hepatitis 
  • Meningitis
  • Osteomyelitis
  • Pseudomembranous colitis
  • Parotitis
  • Perineal infections
  • Peritonitis
  • Pharyngitis
  • Pneumonia 
  • Retained foreign body 
  • Sinusitis 
  • Soft tissue infection
  • Tracheobronchitis
  • Urinary tract infection
  • Acute hepatic necrosis
  • Adrenal insufficiency 
  • Allergic reaction
  • Atelectasis
  • Dehydration
  • Drug reaction 
  • Head injury
  • Hepatoma
  • Hyperthyroidism
  • Lymphoma
  • Myocardial infarction
  • Pancreatitis
  • Pheochromocytoma
  • Pulmonary embolus 
  • Retroperitoneal hematoma 
  • Solid organ hematoma
  • Subarachnoid hemorrhage
  • Systemic inflammatory response syndrome 
  • Thrombophlebitis
  • Transfusion reaction
  • Withdrawal syndromes 
  • Wound infection

 

수술 후 발열(Postoperative fever)의 시기에 따른 흔한 원인

24시간 내

  • 수술에 의한 정상 염증 반응

 

48~72시간 내

  • 무기폐(atelectasis)
  • 상처부위 감염(clostridial or streptococcal infection이 있을 수 있으나 드묾)

 

5-8 일

  • 6“W”s
    • Wind(Lung): 폐렴, 폐색전증, DVT
    • Wound: 상처부위 감염, 정맥혈전염
    • Water(urinary tract): 요로감염
    • Waste(lower GI tract):pseudomembranous colitis, 복부내 농양
    • Wonder drug: e.g. antibiotics
    • Walker: e.g. thrombosis

 

  • 수술 후 감염 빈도: UTI(m/c) >Pulmonary infection >Wound infection > Bacteremia

 

원인을 이해하기 쉽게 이니셜 W로 제시하는 경우가 많은데 교과서, 논문마다 5W's, 6 W's, 7 W'로 다소 다르게 제시하고 있다.

(sabiston 20판에서는 6 W's를 제시하고 있다.

5‘W’

6'W's

7W's 

  • Wind (POD#0; Atelectasis, pneumonia)
  • Water (POD#3; UTI)
  • Wounds (POD#5; leak, wound infection, hematoma, abscess) 
  • Wonder drugs(anaesthetics, drug reactions)
  • Walking(DVT/PE)
  • Wind(Lung): 폐렴, 폐색전증, DVT
  • Wound: 상처부위 감염, 정맥혈전염
  • Water(요로감염)
  • Waste(하부 위장관): pseudomembranous colitis, 복부내 농양
  • Wonder drug(antibiotics)
  • Walker(thrombosis)
  • Wind
  • Water
  • Wound
  • Walking
  • Wonder drugs
  • Withdrawal
  • “Wonky” glands

DVT, PE, thrombophlebitis, drug, transfusion, UIT, line sepsis, heart valves의 경우는 어떠한 시간에도 발생이 가능하다고 알려져 있으며, 수술 당일에는 Malignant hyperthermia, anaesthetics, aspiration, endocrine factor, 수술 1-2일까지는 atelectasis, streptococcal/clostridial wound infection, 수술 후 3-5일 사이에는 pneumonia, wound complication(anastomotic leak, hematoma, infection) 수술 후 6일 이상의 경우에는 wound infection/abscess, infected hematoma, C. diff colitis, pneumonia가 발생 가능합니다.


 

 

수술 후 발열의 원인에 따른 조치

원인

 

시간

평가 및 조치

Wind

Atelectasis

< 48

Incentive spirometry, pulmonary toilet, early mobilization

Pneumonia

> 48

Chest radiograph, sputum culture, antibiotics

Water

UTI

> 48

Removal of catheter, urinalysis, urine culture, antibiotics

Wound

SSI

> 72

Screening complete blood cell count with differential and antibi-otics (for a superfi cial SSI) and radiography, OR or interventional radiology drainage, culture, and antibiotics (for a deep or organ/space SSI)

Walking

DVT

 > 72 

Venous Doppler ultrasound, sequential compression devices

Wonder drugs

Medications

Any

Review medication history and patient history, stop suspected medications, provide supportive care

Withdrawal

Delirium tremens

> 72

Review patient history, administer benzodiazepine, consult psychiatry

“Wonky” glands

Adrenal insufficiency

< 12

Review patient history and medi-cation history, administer fl uid resuscitation and glucocorticoids

Thyroid storm

< 48

Review patient history, administer a beta-blocker, a thionamide, and iodine and consult endrocrinology


참고자료

  • 대한외과학회. 외과학 2판(2017). 13장
  • Sabiston Textbook of Surgery. 20판(2017). 12장
  • Maday KR, Hurt JB, Harrelson P, Porterfield J. Evaluating postoperative fever. JAAPA 2016;29(10):23–8.
  • Narayan M, Medinilla SP. Fever in the postoperative patient. Emerg Med Clin North Am 2013;31(4):1045–58.
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