This case involves a pediatric patient who had surgery for a chronic back condition. After the surgery, it was noted that the patient’s abdomen was distended, and that he was having trouble tolerating feeding. The patient developed a high fever and blood cultures were ordered to be drawn from his central line. Despite having multiple elevated temperatures and tachycardia, the patient was treated with only over-the-counter medications. The patient’s conditioned worsened, and he was noted to become non-verbal and confused with spiking fevers. Lab results showed an elevated white blood cell count and blood cultures that were positive for a bacterial infection. A combination of antibiotics were ordered at this time, including Avelox. Shortly after the antibiotics were started, the patient developed cardiovascular collapse and died in the hospital. It was claimed that the patient should have been observed more closely following his surgery.
Question(s) For Expert Witness
- 1. Do you have extensive experience treating patient with similar symptoms?
- 2. How are fevers usually worked up in patients postop?
- 3. When there is suspicion of an infectious source for a fever, how soon should blood cultures and white blood cell counts be taken?
- 4. When is it appropriate to start a trial of antibiotics in a febrile post op patient?
Expert Witness Response E-047447
I have extensive experience treating patients post scoliosis repair and dealing with post operative complications and sepsis. Working up fever in a post-op patient is dependent on the type of surgery and the timing of the fever. It would not be abnormal for a patient to have post-operative fever for a few days and not require any work up. That being said, patient risk factors, comorbidities and the hospitalization course contribute to what may need to be done; an expedient work-up with CBC, blood cultures, X-rays, and antibiotic administration could be warranted. In the vast majority of cases, work up with CBC and blood cultures should be performed unless a viral etiology is suspected. Starting the patient on a trial of antibiotics and keeping them on for 24 hours is reasonable for most cases.
Expert Witness Response E-047741
As an attending in Infectious Diseases, I have consulted on and reviewed multiple cases similar to the described scenario. I have lectured on management of fevers in the hospital setting. In a post-op patient, common reasons for a fever in the first 24-48 hours are atelectasis or pneumonia, so a chest x-ray is often ordered. Blood counts and C- reactive protein can also be ordered to work up a febrile patient. When the source of fever is not readily known, the surgical team will then place a consult to a medical specialist (hospitalist or infectious disease teams). A blood count or CBC is obtained for post- op patients and whenever there is suspicion of an infectious etiology for fever. Blood cultures would be obtained when the patient is clinically unstable or when the fevers are persistent. Antibiotics are started when an infectious source has been identified and after cultures have been obtained. It is not really reasonable to start antibiotics in a stable patient.