Clinical Pearls in Perioperative Medicine

Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
Mayo Clinic Proceedings (Impact Factor: 6.26). 07/2009; 84(6):546-50. DOI: 10.1016/S0025-6196(11)60586-7
Source: PubMed


At the 2001 annual meeting of the American College of Physicians (ACP), a new and innovative teaching format, the "Clinical Pearls" session, was introduced. Clinical Pearls sessions were designed to teach physicians using clinical cases. The session format involves specialty speakers presenting a number of short cases to a physician audience. Each case is followed by a multiple-choice question, answered by each attendee using an electronic audience-response system. After a summary of the answer distribution is shown, the correct answer is displayed and the speaker discusses important teaching points and clarifies why one answer is most clinically appropriate. Each case presentation ends with 1 or 2 "Clinical Pearls," defined as a practical teaching point, supported by the literature, and generally not well known to most internists. The Clinical Pearls sessions are consistently one the most popular and well attended sessions at the American College of Physicians' national meeting each year. Herein, we present the Clinical Pearls in Perioperative Medicine, presented at the ACP National Meeting in San Francisco, California, April 11-13, 2013.

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    ABSTRACT: Postoperative fever should be evaluated with a focused approach rather than in "shotgun" fashion. Most fevers that develop within the first 48 hours after surgery are benign and self-limiting. However, it is critical that physicians who provide postoperative care be able to recognize the minority of fevers that demand immediate attention, based on the patient's history, a targeted physical examination, and further studies if appropriate. Fever that develops after the first 2 days following surgery is more likely to have an infectious cause, but noninfectious causes that require further evaluation and treatment must also be considered. When evaluating postoperative fever, a helpful mnemonic is the "four Ws": wind (pulmonary causes: pneumonia, aspiration, and pulmonary embolism, but not atelectasis), water (urinary tract infection), wound (surgical site infection), "what did we do?" (iatrogenic causes: drug fever, blood product reaction, infections related to intravenous lines).
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    ABSTRACT: Documentation of the normal fever response after total knee and hip replacement is important to avoid an unnecessary workup for sepsis, and to provide justification for early discharge (dictated by the current medical reimbursement climate) despite persistent postoperative fever. One hundred patients who underwent total knee arthroplasty and 100 patients who underwent total hip arthroplasty were reviewed, several of whom had extensive sepsis workups for evaluation of postoperative fever. No patient in this series had a documented joint infection. All patients were treated with warfarin for deep vein thombrosis prophylaxis. All patients used incentive spirometry and were started on ambulation training on postoperative Day 1. All were given antibiotic prophylaxis for 48 hours. The maximum daily postoperative temperature occurred in most patients on postoperative Day 1 and gradually leveled off toward normal by postoperative Day 5. Only one patient had a maximum temperature on postoperative Day 4 that was greater than that on postoperative Day 3. Patients undergoing revision procedures tended to have a more pronounced febrile response, but the differences were not statistically significant. No significant differences were seen between patients who had epidural anesthesia and patients who had general anesthesia. Seventeen patients had postoperative chest radiographs for evaluation of fever. None had significant atelectasis. The presence of a positive urine culture had no effect on the fever response, with most positive results being identified after the fever had returned toward normal. Postoperative fever after total joint arthroplasty is a normal inflammatory response. A workup for sepsis is not indicated in the perioperative period unless corroborating signs or symptoms are present. Early discharge is appropriate if the febrile response is decreasing progressively.
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