Delaying surgery in an infected patient
Late one Friday, an elderly man was admitted to the emergency department with a fractured hip from a recent fall. He had an unexplained fever of 102.5°F with a slight possibility of early upper respiratory infection (URI). The surgeon wanted to perform an emergency operation, but the anesthesiologist recommended waiting to allow the patient to be examined by an internist over the weekend. Was this the right decision?—JERRY PARKER, BHS, CRNA, Islamorada, Fla.
This comes down to benefits vs. risks. Although hip fracture is a surgical disease, medical consultation is almost always involved in the care of these patients. At most urban and suburban hospitals, a hospitalist is available at all times to ensure minimal delay in the process of optimizing and clearing the patient for surgery. The literature recommends surgery within 24-48 hours in patients who are medically stable and who do not have significant comorbid disease. In patients with a comorbid condition or active infection, surgery can probably be delayed for 72 hours without incurring substantial harm; however, delay beyond 72 hours should be avoided (Clin Orthop Relat Res. 2004;428:294-301 and J Bone Joint Surg Am. 1995;77:1551-1556). Active infection includes sepsis, pneumonia, and UTI. In concert with the history and physical examination, these infections can be evaluated quickly with lactic acid, chest x-ray, and urinalysis, respectively. A fever of 102.5°F in an elderly patient is higher than is usually observed in a URI such as the common cold but could be seen in influenza.—JoAnn Deasy, PA-C, MPH (134-3)