Fever after craniofacial surgery in the infant under 24 months of age

[Prospective analysis of inflammatory markers and perioperative clinical data in children with craniosynostosis undergoing reconstructive surgery]

BACKGROUND

Craniosynostosis (CS) is a group of skull malformations manifested by congenital absence or premature closure of cranial sutures. Reconstructive surgery in the second half of life is traditional approach for CS. The issues of surgical stress response after reconstructive surgery for CS in children are still unclear.

OBJECTIVE

To evaluate clinical and laboratory parameters in children undergoing traumatic reconstructive surgery for CS.

MATERIAL AND METHODS

Inclusion criteria were CS, reconstructive surgery, age <24 months, no comorbidities and available laboratory diagnostic protocol including complete blood count, biochemical blood test with analysis of C-reactive protein, procalcitonin, ferritin and presepsin. The study included 32 patients (24 (75%) boys and 8 (25%) girls) aged 10.29±4.99 months after surgery between October 2021 and June 2022. Non-syndromic and syndromic forms of CS were observed in 25 (78.1%) and 7 (21.9%) cases, respectively.

RESULTS

There were no infectious complications. We analyzed postoperative clinical data, fever, clinical and biochemical markers of inflammation.

CONCLUSION

Early postoperative period after reconstructive surgery for CS in children is accompanied by significant increase of inflammatory markers (C-reactive protein, procalcitonin, ferritin). However, these findings do not indicate infectious complications. This is a manifestation of nonspecific systemic reaction. Severity of systemic inflammatory response syndrome with increase in acute phase proteins indicates highly traumatic reconstructive surgery for CS in children. Analysis of serum presepsin allows for differential diagnosis between infectious complication and uncomplicated course of early postoperative period.

Development of Calvarial Bone Osteomyelitis in a Noonan Syndrome Patient Following Fronto-Orbital Advancement of Craniosynostosis: A Novel Technique of Treatment Using Povidone and Hydrogen Peroxide Solutions

This is a case of a pediatric patient with Noonan syndrome (NS) and craniosynostosis who developed calvarial bone osteomyelitis following corrective surgery. Despite complications, such as postoperative bleeding and infections, including osteomyelitis, multidisciplinary management strategies were employed, including antibiotics, debridement, and novel use of hydrogen peroxide and povidone solutions due to bone thinning. The discussion highlights challenges in managing syndromic craniosynostosis, emphasizing the importance of tailored approaches and prophylactic antibiotics. The innovative treatment approach using hydrogen peroxide and povidone presents a potential alternative for bone infections and osteomyelitis post-cranial reconstruction, offering insights for future management strategies. Lessons learned regarding infection rates and novel treatment modalities contribute to evolving approaches in managing complications in syndromic craniosynostosis.

Postoperative fever secondary to enoxaparin usage with pork allergy

Postoperative fevers are common in hospitalised patients and warrant workup beyond the early post-op period. A 50-year-old man was admitted after sustaining a tibial plateau fracture. Fevers began 3 days after external fixation and persisted through a second surgery despite initial negative workup. Careful review of medications revealed enoxaparin as the instigating agent of a febrile drug reaction, and the fevers resolved after discontinuing the drug. On further questioning, it was discovered the patient had an allergy to pork, from which the main components of enoxaparin are typically derived. To our knowledge, this is the first reported enoxaparin-induced fever in the setting of a pork allergy. Enoxaparin-induced fevers should be considered in patients with unexplained post-op fever. Our case demonstrates the importance of analysing newly administered medications. Simple detailed history may significantly reduce patient morbidity and help to broaden differentials during investigation.

Postoperative Non-Pathological Fever Following Posterior Cervical Fusion Surgery : Is Laminoplasty a Better Preventive Method than Laminectomy?

Objective

To analyze the incidence and characteristics of delayed postoperative fever in posterior cervical fusion using cervical pedicle screws (CPS).

Methods

This study analyzed 119 patients who underwent posterior cervical fusion surgery using CPS. Delayed fever was defined as no fever for the first 3 postoperative days, followed by an ear temperature ≥38℃ on postoperative day 4 and subsequent days. Patient age, sex, diagnosis, laminectomy, surgical level, revision status, body mass index, underlying medical disease, surgical duration, and transfusion status were retrospectively reviewed.

Results

Of 119 patients, seven were excluded due to surgical site infection, spondylitis, pneumonia, or surgical level that included the thoracic spine. Of the 112 included patients, 28 (25%) were febrile and 84 (75%) were afebrile. Multivariate logistic regression analysis showed that laminectomy was a statistically significant risk factor for postoperative non-pathological fever (odds ratio, 10.251; p=0.000). In contrast, trauma or tumor surgery and underlying medical disease were not significant risk factors for fever.

Conclusion

Patients who develop delayed fever 4 days after posterior cervical fusion surgery using CPS are more likely to have non-pathologic fever than surgical site infection. Laminectomy is a significant risk factor for non-pathologic fever.

The Incidence of and Risk Factors for Postoperative Fever after Cleft Repair Surgery in Children

PURPOSE

The characteristics of postoperative fever after cleft repair surgery in children are unknown. Thus, the purpose of this study was to determine the incidence of and risk factors for postoperative fever.

DESIGN AND METHODS

We retrospectively assessed 328 children who underwent cleft surgery at our hospital between March 2016 and April 2017 and were followed up for at least 3 days postoperatively. Fever was defined as a body temperature ≥38.0 °C.

RESULTS

Seventy-one percent (n = 233) of patients developed fever within 72 h postoperatively, and most cases of postoperative fever were benign. Patients most frequently developed fever within 24 h postoperatively, and the occurrence of fever significantly decreased between 24 and 72 h postoperatively (p < 0.001). The incidence of fever with temperatures between 38.0 °C and 39.0 °C was higher than that of fever with temperatures ≥39.0 °C (p < 0.001). The mean duration of an episode of fever was 4 h. The type of surgery, method of anesthesia, and duration of anesthesia and surgery were found to be correlated with postoperative fever after cleft surgery.

CONCLUSIONS

Most cases of postoperative fever after cleft surgery were benign occurrences. Postoperative fever after cleft repair surgery was characterized by a low grade, an early onset and a short duration in children. The method of anesthesia, duration of surgery and duration of anesthesia were risk factors for postoperative fever.

PRACTICE IMPLICATIONS

Our results could help healthcare providers to gain increased knowledge of the risk factors for fever and when and how to treat postoperative fever.

Leukocytosis is common after orthognathic surgery: A retrospective study

INTRODUCTION

In the absence of infection-specific clinical signs and symptoms, it is often difficult for the maxillofacial surgeon to decide whether leukocytosis after orthognathic surgery is part of the normal postoperative response, as suggested for a variety of non-maxillofacial surgeries, or a sign of a developing infection. The aim was to determine the trends and factors predictive of postoperative WBC (white blood cell) values after orthognathic surgery that may provide the surgeon appropriate guidance for decision making.

MATERIALS AND METHODS

This retrospective cohort study included a total of 83 consecutive patients who underwent 93 orthognathic surgical cases over six years. The natural history of postoperative WBC values and incidence of leukocytosis were characterized, and their differences across potential predictor variables were then analyzed using univariate analysis and multivariate regression analysis.

RESULTS

On post-operative day (POD) 1, the mean post-operative WBC count reached the peak level, with an increase of 11.4 × 10⁶ cells/μL. By POD 2, it declined slightly to a level approximately two times more than the preoperative level. Over the first two post-operative days, the incidence of leukocytosis was 93.5%. Multivariate regression analyses revealed that gender, duration of surgery and pre-operative WBC count were the only significant predictors of the post-operative WBC value, whereas the pre-operative WBC count was the only significant (OR: 2.61, P < 0.05) predictor of post-operative leukocytosis.

CONCLUSION

Post-operative leukocytosis after orthognathic surgery is significantly influenced by the pre-operative WBC count, and has similar trends with a much higher incidence, compared to non-maxillofacial surgeries.

Minimizing Complications Related to Fever in the Postoperative Pediatric Oncology Patient

Fever is a common postoperative complication that is generally thought to be a benign, self-limiting event. However, for pediatric oncology patients who are often immunocompromised, a postoperative fever may indicate an infection, which can lead to significant complications if not treated promptly. A physical examination, which is an established cost-effective method to rule out infections in the general surgical population, may not be sufficient for oncology patients because clinical symptoms may be atypical or absent in immunocompromised hosts. Although a full septic workup may be unnecessary, additional investigations such as blood cultures may be warranted, and antibiotic therapy should be considered for some or all febrile postoperative cancer patients. No standardized approach to fever management in postoperative oncology patients currently exists, which can present a challenge for those who care for these patients. In the absence of such established practice standards, this article outlines some of the considerations that may be vital in minimizing complications related to fever in the postoperative pediatric oncology patient.

Fever after maxillofacial surgery: a critical review

PURPOSE

The aim of this paper is to review the pathophysiology of thermoregulation mechanism, various causes of fever after maxillofacial surgery and the different treatment protocols advised in the literature.

DISCUSSION

Fever is one of the most common complaints after major surgery and is also considered to be an important clinical sign which indicates developing pathology that may go unnoticed by the clinician during post operative period. Several factors are responsible for fever after the maxillofacial surgery, inflammation and infection being the commonest. However, other rare causes such as drug allergy, dehydration, malignancy and endocrinological disorders, etc. should be ruled out prior to any definite diagnosis and initiate the treatment. Proper history and clinical examination is an essential tool to predict the causative factors for fever. Common cooling methods like tepid sponging are usually effective alone or in conjunction with analgesics to reduce the temperature.

CONCLUSION

Fever is a common postoperative complaint and should not be underestimated as it may indicate a more serious underlying pathology. A specific guideline towards the management of such patients is necessary in every hospital setting to ensure optimal care towards the patients during post operative period.

Intensive care unit course of infants and children after cranial vault reconstruction for craniosynostosis

BACKGROUND

Craniosynostosis (CSS) results from the premature closure of one or more cranial sutures, leading to deformed calvaria at birth. It is a common finding in children with an incidence of one in 2000 births. Surgery is required in order to release the synostotic constraint and promote normal calvaria growth. Cranial vault remodeling is the surgical approach to CSS repair at our institution and it involves excision of the frontal, parietal, and occipital bones. The purpose of this article is to describe the post-operative course of infants and children admitted to our PICU after undergoing cranial vault remodeling for primary CSS.

FINDINGS

Complete data was available for analyses in only 82 patients, 44 males (M) and 38 females (F); M: F ratio was 1:1.2. Patients (pts) age in months (mo) ranged from 2 mo to 132 mo, mean 18.2 ±-24.9 mo and weights (wt) ranged from 4.7 kg to 31.4 kg, mean 10.24 ± 5.5 Kg.. Duration of surgery (DOS) ranged from 70 minutes to 573 minutes mean 331.6 ± 89.0 minutes. No significant correlation exist between duration of surgery, suture category, patient's age or use of blood products (P > 0.05). IOP blood loss was higher in older pts (P < 0.05) and it correlates with body temperature in the PICU (P < .0001). Post-op use of FFP correlated with intra-operative PRBC transfusion (P < 0.0001). More PRBC was transfused within 12 hrs-24 hrs in PICU compared to other time periods (P < 0.05). LOS in PICU was < 3 days in 68% and > 3 days in 32%. Pts with fever had prolonged LOS (P < 0. 05); re-intubation rate was 2.4% and MVD were 1.83 days. Repeat operation for poor cosmetic results occurred in 9.7% of pts.

CONCLUSIONS

Post-op morbidities from increased use of blood products can be minimized if cranial vault remodeling is done at a younger age in patients with primary CSS. PICU length of stay is determined in part by post-op pyrexia and it can be reduced if extensive evaluations of post-op fever are avoided.

Is it possible to shorten the jaws using contraction osteogenesis?

PURPOSE

This study investigated whether shortening of osteotomized jaws is possible.

MATERIALS AND METHODS

Nine sheep were used (2 as controls and 7 as experimental subjects). Distraction devices that had previously been activated to 10 mm were fixed to the mandibles of all animals bilaterally and used in reverse as a contraction device. Control and experimental animals were sacrificed at 1 month and 3 months. Bone in the area of contraction was evaluated using radiodensitometry and microscopy.

RESULTS

The mandibles were shortened an average of 5.5 mm. Exaggerated bone formation was seen around the osteotomized cortical bone. When histologic slices from experimental animals were examined 1 month after the contraction period, fibrous pseudoarthrosis formation was seen centrally, with hyaline cartilage around it, whereas normal bone formation was seen in the outer part. The hyaline cartilage had turned into normal bone 3 months after the end of contraction.

CONCLUSIONS

It is possible to shorten bones using contraction osteogenesis.

Postoperative fevers in pediatric solid tumor patients: how should they be managed?

It is unclear how aggressively postoperative fevers should be managed in immunosuppressed pediatric oncology patients after major surgery. Little data exists on this subject. Therefore, a retrospective study of patients treated at our center was undertaken to examine this.

PURPOSES

(1) to describe the prevalence of fever and infection in postoperative pediatric solid tumor patients undergoing primary tumor resection, (2) to examine the risk factors that contribute to the development of postoperative infections, and (3) to describe the variation in practice in managing fevers.

METHODS

Chart reviews were performed on patients diagnosed with a spectrum of tumor types from January 2000 to October 2005 who received preoperative chemotherapy, followed by tumor resection.

RESULTS

Ninety-eight children met inclusion criteria and 73 (74%) developed fevers postoperatively; 14% of these had documented infections and 1 patient died from sepsis. Factors associated with increased risk of infection were a diagnosis of neuroblastoma (P=0.015), and surgery longer than 8 hours (P=0.059). The investigation and management of postoperative fevers varied in these patients.

CONCLUSIONS

Postoperative fevers may be indicative of severe infection. We suggest that a standardized approach to the management of these patients, including prompt physical assessment, clinical investigations, and empiric antibiotic consideration is vital to minimize complications.

Hyperthermia during anaesthesia and intensive care unit stay

Nosocomial hyperthermia (fever) occurs in about 30% of all medical patients at some time during their hospital stay. In patients admitted to the intensive care unit with severe sepsis the incidence of hyperthermia is greater than 90%, while in a specialized neurological critical care unit the incidence is reported as 47%. In contrast, hyperthermia during anaesthesia is rare owing to the impairment of thermoregulation by anaesthetic agents. This article is designed to give an overview on the various causes of hyperthermia with special emphasis on fever during general and regional anaesthesia in general and neurological critical care patients.

Complications in the surgical treatment of craniosynostosis and craniofacial syndromes: apropos of 306 transcranial procedures

OBJECTIVE

To review the complications in the surgical treatment of craniosynostosis in 306 consecutive transcranial procedures between June 1999 and June 2007.

PATIENTS AND METHODS

Surgical series consist of 306 procedures done in 268 patients: 155 scaphocephalies, 50 trigonocephalies, 28 anterior plagiocephalies, one occipital plagiocephaly, 20 non-syndromic multisutural synostosis and 32 craniofacial syndromes (11 Crouzon, 12 Apert, seven Pfeiffer and two Saethre-Chotzen) Complications and time of hospitalisation were reckoned. Surgical procedures were classified in 12 different types according to the technique: Type I: frontal-orbital distraction (26 cases); Type II: endoscopic assisted osteotomies in sagittal synostosis (39 cases); Type III: sagittal suturectomy and expansive osteotomies (44 cases); Type IV: same as type III, but including frontal dismantling or frontal osteotomies in scaphocephalies (59 cases); Type V: complete cranial vault remodelling (holocranial dismantling) in scaphocephalies (13 cases); Type VI: frontal-orbital remodelling without frontal-orbital bandeau in trigonocephaly (50 cases); Type VII: frontal-orbital remodelling without frontal-orbital bandeau in plagiocephaly (14 cases); Type VIII: frontal-orbital remodelling with frontal-orbital bandeau in plagiocephaly (14 cases); Type IX: Occipital advancement in posterior plagiocephaly (one case); Type X: Standard bilateral front-orbital advancement with expansive osteotomies (28 cases); Type XI: holocranial dismantling (complete cranial vault remodelling) in multisutural craniosynostosis (12 cases); Type XII: occipital and suboccipital craniectomies in multiple suture craniosynostosis (six cases).

RESULTS

There was no mortality and all complications resolved without permanent deficit. Mean age at surgery was 6.75 months. Most frequent complication was non-filiated postoperative hyperthermia (13.17% of the cases) followed by infection (8.10%), subcutaneous haematoma (6.08%), dural tears (5.06%) and cerebrospinal fluid (CSF) leakage (2.7%). Number and type of complications was higher among the group of reoperated patients (12.8% of all): 62.5% of all the series infections, 93% of all dural tears and 75% of all CSF leaks. In relation to surgical procedures, endoscopic assisted osteotomies reported the lowest rate of complications, followed by standard frontal-orbital advancement in multiple synostosis, trigonocephalies and plagiocephalies. Highest number of complications was related to complete cranial vault remodelling (holocranial dismantling) in scaphocephalies and multiple synostoses and after the use of internal osteogenic distractors. Special consideration deserves two cases of iatrogenic basal encephaloceles after combined frontal-facial distraction. Finally, we establish considerations based on the complications related to every specific technique.

CONCLUSIONS

Percentage and severity of complications relates to the surgical procedure and is higher among patients going for re-operation. Mean time of hospitalization is also modified by these issues.

Pyrexia after Transcranial Surgery

Pyrexia after transcranial surgery has been observed regularly in clinical practice but does not usually herald any subsequent pathologic process. However, the significance and incidence of this phenomenon remain uncertain. The aim of this study was to evaluate the incidence and timing of any pyrexia after transcranial surgery for craniosynostosis correction and correlate this with the clinical outcome to assess its significance. Retrospective review of sequential case notes collected over a 10 year period identified 136 transcranial operations undertaken for 122 cases of nonsyndromic craniosynostosis. The incidence of postoperative pyrexia of 38 degrees or more in the first 5 days was 76%, whereas that greater than 39 degrees was 11%. Pyrexia was noticed during the first 48 hours and had a bimodal distribution. Only a single case in this series subsequently developed a clinically significant complication, that is, a minor wound infection of the skin, which was treated by antibiotics and dressings. The occurrence of pyrexia did not appear to be related either to sex or to any affected suture but occurred less frequently in those who were under 6 months old. We conclude that this pyrexia should be considered to be a part of the normal physiological response to craniofacial surgery.

Fever during anaesthesia

Fever occurs when pyrogenic stimulation activates thermal control centres. Fever is common during the perioperative period, but rare during anaesthesia. Although only a limited number of studies are available to explain how anaesthesia affects fever, general anaesthesia seems to inhibit fever by decreasing the thermoregulatory-response thresholds to cold. Opioids also inhibit fever; however, the effect is slightly less than that of general anaesthesia. In contrast, epidural anaesthesia does not affect fever. This suggests that hyperthermia, which is often associated with epidural infusions during labour or in the post-operative period, may be a true fever caused by inflammatory activation. Accordingly, this fever might be diminished in patients who receive opioids for pain treatment. Post-operative fever is a normal thermoregulatory response usually of non-infectious aetiology. Fever may be important in the host defence mechanisms and should not be routinely treated lest the associated risks exceed the benefits.