Does Atelectasis Cause Fever After Surgery? Putting a Damper on Dogma

A Case Report of Malaria Infection Following Laparoscopic Sleeve Gastrectomy

A 41-year-old woman from the Democratic Republic of the Congo underwent laparoscopic sleeve gastrectomy (LSG) as a surgical treatment for obesity. Despite an unremarkable preoperative evaluation, the patient developed a fever and elevated C-reactive protein (CRP) levels postoperatively. Physical examination findings, laboratory tests, and imaging studies ruled out surgical complications, leading to the consideration of infectious causes. A thorough patient history revealed a residence in a malaria-endemic region with a history of recurrent malaria episodes. In addition to her complaints, the patient developed pancytopenia. The blood smear revealed the presence of ring forms of Plasmodium falciparum in red blood cells, along with other species of Plasmodium. The rapid diagnostic test (RDT) showed a positive result for the P. falciparum antigen, a negative result for the P. vivax antigen, and a positive result for the pan-antigen. Based on these findings, a mixed malaria infection was considered for the patient, and she was transferred to an advanced infectious disease hospital for specific typing and further treatment. The patient received prompt treatment and was discharged in stable condition. Malaria could potentially be among the uncommon factors leading to fever after bariatric surgery in patients from malaria-endemic countries. Surgical stress may exacerbate the course of a malaria infection.

Early Postoperative Fever and Atelectasis in Patients Undergoing Upper Abdominal Surgery

BACKGROUND

Atelectasis is a common complication after upper abdominal surgery and considered as a cause of early postoperative fever (EPF) within 48 hours after surgery. However, the pathophysiologic mechanism of how atelectasis causes fever remains unclear.

STUDY DESIGN

Data for adult patients who underwent elective major upper abdominal surgery under general anesthesia at Seoul National University Hospital between January and December of 2021 were retrospectively analyzed. The primary outcome was the association between fever and atelectasis within 2 days after surgery.

RESULTS

Of 1,624 patients, 810 patients (49.9%) developed EPF. The incidence of atelectasis was similar between the fever group and the no-fever group (51.6% vs 53.9%, p = 0.348). Multivariate analysis showed no significant association between atelectasis and EPF. Culture tests (21.7% vs 8.8%, p < 0.001) and prolonged use of antibiotics (25.9% vs 13.9%, p < 0.001) were more frequent in the fever group compared to the no-fever group. However, the frequency of bacterial growth on culture tests and postoperative pulmonary complications within 7 days were similar between the two groups.

CONCLUSIONS

EPF after major upper abdominal surgery was not associated with radiologically detected atelectasis. EPF also was not associated with the increased risk of postoperative pulmonary complications, bacterial growth on culture studies, or prolonged length of hospital stay.

The effect of high perioperative inspiratory oxygen fraction for abdominal surgery on surgical site infection: a systematic review and meta-analysis

Guidelines from the World Health Organization strongly recommend the use of a high fraction of inspired oxygen (FiO2) in adult patients undergoing general anesthesia to reduce surgical site infection (SSI). However, previous meta-analyses reported inconsistent results. We aimed to address this controversy by focusing specifically on abdominal surgery with relatively high risk of SSI. Medline, EMBASE, and Cochrane CENTRAL databases were searched. Randomized trials of abdominal surgery comparing high to low perioperative FiO2 were included, given that the incidence of SSI was reported as an outcome. Meta-analyses of risk ratios (RR) were performed using a fixed effects model. Subgroup analysis and meta-regression were employed to explore sources of heterogeneity. We included 27 trials involving 15977 patients. The use of high FiO2 significantly reduced the incidence of SSI (n = 27, risk ratio (RR): 0.87; 95% confidence interval (CI): 0.79, 0.95; I2 = 49%, Z = 3.05). Trial sequential analysis (TSA) revealed that z-curve crossed the trial sequential boundary and data are sufficient. This finding held true for the subgroup of emergency operations (n = 2, RR: 0.54; 95% CI: 0.35, 0.84; I2 = 0%, Z = 2.75), procedures using air as carrier gas (n = 9, RR: 0.79; 95% CI: 0.69, 0.91; I2 = 60%, Z = 3.26), and when a high level of FiO2 was maintained for a postoperative 6 h or more (n = 9, RR: 0.68; 95% CI: 0.56, 0.83; I2 = 46%, Z = 3.83). Meta-regression revealed no significant interaction between SSI with any covariates including age, sex, body-mass index, diabetes mellitus, duration of surgery, and smoking. Quality of evidence was assessed to be moderate to very low. Our pooled analysis revealed that the application of high FiO2 reduced the incidence of SSI after abdominal operations. Although TSA demonstrated sufficient data and cumulative analysis crossed the TSA boundary, our results should be interpreted cautiously given the low quality of evidence.Registration: https://www.crd.york.ac.uk/prospero (CRD42022369212) on October 2022.

A Novel Comprehensive Algorithm for Evaluation of PICU Patients With New Fever or Instability

OBJECTIVES

There is variation in microbiology testing among PICU patients with fever offering opportunities to reduce avoidable testing and treatment. Our objective is to describe the development and assess the impact of a novel comprehensive testing algorithm to support judicious testing practices and expanded diagnostic differentials for PICU patients with new fever or instability.

DESIGN

A mixed-methods quality improvement study.

SETTING

Single-center academic PICU and pediatric cardiac ICU.

SUBJECTS

Admitted PICU patients and physicians.

INTERVENTIONS

A multidisciplinary team developed a clinical decision-support algorithm.

MEASUREMENTS AND MAIN RESULTS

We evaluated blood, endotracheal, and urine cultures, urinalyses, and broad-spectrum antibiotic use per 1,000 ICU patient-days using statistical process control charts and incident rate ratios (IRRs) and assessed clinical outcomes 24 months pre- and 18 months postimplementation. We surveyed physicians weekly for 12 months postimplementation. Blood cultures declined by 17% (IRR, 0.83; 95% CI, 0.77-0.89), endotracheal cultures by 26% (IRR, 0.74; 95% CI, 0.63-0.86), and urine cultures by 36% (IRR, 0.64; 95% CI, 0.56-0.73). There was an anticipated rise in urinalysis testing by 23% (IRR, 1.23; 95% CI, 1.14-1.33). Despite higher acuity and fewer brief hospitalizations, mortality, hospital, and PICU readmissions were stable, and PICU length of stay declined. Of the 108 physician surveys, 46 replied (43%), and 39 (85%) recently used the algorithm; 0 reported patient safety concerns, two (4%) provided constructive feedback, and 28 (61%) reported the algorithm improved patient care.

CONCLUSIONS

A comprehensive fever algorithm was associated with reductions in blood, endotracheal, and urine cultures and anticipated increase in urinalyses. We detected no patient harm, and physicians reported improved patient care.

Actual compliance rate of Enhanced Recovery After Surgery protocol in laparoscopic distal gastrectomy

Purpose

The Enhanced Recovery After Surgery (ERAS) protocol enhances recovery rate after laparoscopic distal gastrectomy (LDG). An ERAS protocol has been applied to most patients who underwent LDG at our center. In this study, we determined the actual compliance rate of the ERAS protocol and analyzed the risk factors for noncompliance.

Methods

Medical records of 1,013 patients who underwent LDG from March 2016 to December 2017 were reviewed retrospectively. The compliance group (A) included 327 patients who were discharged within four days postoperatively. The noncompliance group (B) comprised 686 patients who were not discharged within four days postoperatively.

Results

The compliance rate of the ERAS protocol was 32.3%. Potential compliance rate was 53.2%. Most common reasons for noncompliance were fever (n = 115) and ileus (n = 111). The 30-day emergency room visit rate was significantly lower in group A than that in group B (p = 0.006). Median age, American Society of Anesthesiologists (ASA) physical status classification, operation time, and pathologic stage were significantly higher in group B than those in group A (p < 0.001, p < 0.001, p = 0.005, and p < 0.001, respectively). Risk factors for noncompliance were ASA classification of ≥III (odds ratio [OR], 2.251; p = 0.007), age of ≥70 years (OR, 1.572; p = 0.004), operation time of ≥180 minutes (OR, 1.475; p = 0.003), and pathologic stage of ≥III (OR, 2.224; p < 0.001).

Conclusion

The current ERAS protocols should be applied to patients without risk factors.

Effects of preoperative physiotherapy on signs and symptoms of pulmonary collapse and infection after major abdominal surgery: secondary analysis of the LIPPSMAck-POP multicentre randomised controlled trial

Background

Preoperative education and breathing exercise training by a physiotherapist minimises pulmonary complications after abdominal surgery. Effects on specific clinical outcomes such as antibiotic prescriptions, chest imaging, sputum cultures, oxygen requirements, and diagnostic coding are unknown.

Methods

This post hoc analysis of prospectively collected data within a double-blinded, multicentre, randomised controlled trial involving 432 participants having major abdominal surgery explored effects of preoperative education and breathing exercise training with a physiotherapist on postoperative antibiotic prescriptions, hypoxemia, sputum cultures, chest imaging, auscultation, leukocytosis, pyrexia, oxygen therapy, and diagnostic coding, compared to a control group who received a booklet alone. All participants received standardised postoperative early ambulation. Outcomes were assessed daily for 14 postoperative days. Analyses were intention-to-treat using adjusted generalised multivariate linear regression.

Results

Preoperative physiotherapy was associated with fewer antibiotic prescriptions specific for a respiratory infection (RR 0.52; 95% CI 0.31 to 0.85, p = 0.01), less purulent sputum on the third and fourth postoperative days (RR 0.50; 95% CI 0.34 to 0.73, p = 0.01), fewer positive sputum cultures from the third to fifth postoperative day (RR 0.17; 95% CI 0.04 to 0.77, p = 0.01), and less oxygen therapy requirements (RR 0.49; 95% CI 0.31 to 0.78, p = 0.002). Treatment effects were specific to respiratory clinical coding domains.

Conclusions

Preoperative physiotherapy prevents postoperative pulmonary complications and is associated with the minimisation of signs and symptoms of pulmonary collapse/consolidation and airway infection and specifically results in reduced oxygen therapy requirements and antibiotic prescriptions.

Trial registration

ANZCTR 12613000664741; 19/06/2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-021-00206-3.

Effects of high versus low inspiratory oxygen fraction on postoperative clinical outcomes in patients undergoing surgery under general anesthesia: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To determine whether high perioperative inspired oxygen fraction (FiO₂) compared with low FiO₂ has more deleterious postoperative clinical outcomes in patients undergoing non-thoracic surgery under general anesthesia.

DESIGN

Meta-analysis of randomized controlled trials.

SETTING

Operating room, postoperative recovery room and surgical ward.

PATIENTS

Surgical patients under general anesthesia.

INTERVENTION

High perioperative FiO₂ (≥0.8) vs. low FiO₂ (≤0.5).

MEASUREMENTS

The primary outcome was mortality within 30 days. Secondary outcomes were pulmonary outcomes (atelectasis, pneumonia, respiratory failure, postoperative pulmonary complications [PPCs], and postoperative oxygen parameters), intensive care unit (ICU) admissions, and length of hospital stay. A subgroup analysis was performed to explore the treatment effect by body mass index (BMI).

MAIN RESULTS

Twenty-six trials with a total 4991 patients were studied. The mortality in the high FiO₂ group did not differ from that in the low FiO₂ group (risk ratio [RR] 0.91, 95% confidence interval [CI] 0.42-1.97, P = 0.810). Nor were there any significant differences between the groups in such outcomes as pneumonia (RR 1.19, 95% CI 0.74-1.92, P = 0.470), respiratory failure (RR 1.29, 95% CI 0.82-2.04, P = 0.270), PPCs (RR 1.05, 95% CI 0.69-1.59, P = 0.830), ICU admission (RR 0.94, 95% CI 0.55-1.60, P = 0.810), and length of hospital stay (mean difference [MD] 0.27 d, 95% CI -0.28-0.81, P = 0.340). The high FiO₂ was associated with postoperative atelectasis more often (risk ratio 1.27, 95% CI 1.00-1.62, P = 0.050), and lower postoperative arterial partial oxygen pressure (MD -5.03 mmHg, 95% CI -7.90- -2.16, P < 0.001)_. In subgroup analysis of BMI >30 kg/m², these parameters were similarly affected between the groups.

CONCLUSIONS

The use of high FiO₂ compared to low FiO₂ did not affect the short-term mortality, although it may increase the incidence of atelectasis in adult, non-thoracic patients undergoing surgical procedures. Nor were there any significant differences in other secondary outcomes.

Clinical course of coronavirus disease 2019 in 11 patients after thoracic surgery and challenges in diagnosis

OBJECTIVES

To illustrate the clinical course and difficulties in early diagnosis of coronavirus disease 2019 (COVID-19) in patients after thoracic surgery.

METHODS

We retrospectively analyzed the clinical course of the first 11 patients diagnosed with COVID-19 after thoracic surgery in early January 2020. Postoperative clinical, laboratory, and radiologic records and the time line of clinical course were summarized. Potential prognostic factors were evaluated.

RESULTS

In the 11 confirmed cases (3 female, 8 male), median days from symptom onset to case detection was 8. Insidious symptom onset and misinterpreted postoperative changes on chest computed tomography (CT) resulted in delay in diagnosis. There were 3 fatalities due to respiratory failure, whereas 4 severe and 4 mild cases recovered and were discharged. All patients had once experienced leukocytosis and eosinopenia. Remittent fever and resected lung segments ≥5 were associated with fatality.

CONCLUSIONS

The case fatality rate of postsurgical patients subsequently diagnosed with COVID-19 was 27.3%. Insidious symptom onset, postoperative leukocytosis with lymphopenia, and postsurgical CT changes overshadowed the early signs of viral pneumonia. Dynamic symptom monitoring, serial chest CTs, and tests for viral RNA and serum antibody improve the chance for prompt detection of COVID-19. Consideration should be given to preadmission and preoperative screening and strict contact isolation during the postoperative period.

Women in immunology: 2020 and beyond

Women have been at the forefront of tremendous achievements in immunology in the past decade. However, disparities still exist, limiting upward potential and further advancements. As four NIH intramural women scientists who care deeply about scientific progress and the progress of women in our field, we review ongoing challenges and discuss potential approaches to help advance the promotion of women in the sciences.