Worsening condition after gastric surgery with recurrent fever?
On April 22, my mother was admitted to the hospital after experiencing abdominal pain for several days.
The doctor explained that she had a perforated stomach and needed surgery.
She is 72 years old and has diabetes (controlled with medication) and hypertension (also controlled with medication).
On April 23, she underwent a surgery to remove two-thirds of her stomach and had an anastomosis with the intestines.
The medical orders included total parenteral nutrition and patient-controlled analgesia.
She was placed on a ventilator in the ICU.
From April 24 to May 9, there were no abnormalities for two weeks; she was able to blink and move her limbs in the first few days.
However, her strength continued to decline, and the medical orders indicated poor intestinal motility, which contributed to her weakness.
Eventually, she could not open her eyes or lift her limbs independently.
She then began to experience recurrent fevers.
Upon examination, two abscesses were found, and she underwent drainage and antibiotic treatment.
From May 11 to May 18, the doctor noted muscle cramps.
CT and MRI scans showed no signs of stroke.
The recurrent fevers were suspected to be caused by an infection, and it was advised to improve her strength first.
Therefore, we purchased nutritional supplements (NT$195 per meal) totaling 15 packages, along with additional supplements.
Once her strength improved, she could begin respiratory training to enhance her immune system.
On May 19, her right thigh became swollen, and the physician diagnosed it as a venous embolism, providing treatment with compression bandages.
On May 20, enteral feeding began, and total parenteral nutrition was discontinued.
On May 21, she was transferred to the RCW ward for respiratory training, but she continued to experience recurrent fevers and muscle cramps.
After a CT scan on May 24, during an evening visit, the nurse showed us a syringe filled with the drained pus and relayed that the doctor planned to perform surgery the next day at noon, asking the family to visit the outpatient clinic for an explanation.
On May 25, the doctor explained that the wound was opened but not deeply, and the visible parts were cleaned out, with two drainage tubes placed on either side.
The wound was left open and cleaned daily.
On May 26, she felt able to open her eyes and appeared to be in good spirits.
On May 27, she began receiving sugar water in the evening.
On May 28, she started receiving milk via a pump in the evening.
Between May 29 and June 1, she experienced intermittent low-grade fevers, and the doctor advised continued observation.
On June 2, she vomited some contents in the morning.
The doctor explained that this might be due to excessive absorption and insufficient bowel movements, and an ultrasound was scheduled.
That evening, we were informed that the results were normal.
On June 3, she experienced more significant muscle cramps in the morning.
The doctor could not provide a clear explanation but stated that all tests were normal and that further observation was necessary.
Currently, her overall condition is as follows: she has no strength, slight improvement in intestinal motility, no longer requires total parenteral nutrition, recurrent fevers, and slight reduction in swelling of the right thigh.
It has been over a month since she was admitted to the ICU.
It has been a month since the abscesses were discovered, and she has been experiencing recurrent fevers for nearly five weeks.
I would like to consult with the physician regarding the management of her recurrent fevers and abscesses.
Are there any other recommendations? It feels like the treatment is taking too long, and her condition is worsening.
After one surgery to drain the abscess, she started to have fevers again, and the doctor has been unable to identify the cause of the fever, raising concerns about her ability to endure this situation.
Could you please advise on any treatments or actions that the family can suggest for consideration? Additionally, what assistance or inquiries can we, as family members, provide? Thank you for taking the time to read this amidst your busy schedule.
takashi, 30~39 year old female. Ask Date: 2010/06/03
Dr. Ke Fangxu reply Surgery
Hello: In response to your question, I hope that you can trust that your mother's attending physician is doing everything possible to treat her.
From your letter, it seems that her condition is quite complex, and it is difficult to determine the exact issue based on the provided information.
Gastric perforation in the elderly is indeed very dangerous, as it can lead to peritonitis and sepsis, which are likely to result in mortality.
Additionally, older adults have poorer healing abilities and immune responses, making them more susceptible to complications.
It appears that your mother may have developed an intra-abdominal abscess following surgery, which necessitates another drainage procedure.
Currently, the infection may not have been completely resolved, which could explain the recurrent fevers.
However, it is also possible that the fever is related to respiratory issues (Is there an endotracheal tube in place? Has a tracheostomy been performed?).
The swelling in her thigh is likely due to venous thrombosis, which is often associated with prolonged bed rest and sepsis.
If you have concerns regarding her condition and recovery, it is essential to communicate with the attending physician, as they have the most comprehensive understanding of the situation and the most information.
Sometimes, the recovery process in older adults is not as swift as in younger individuals, but overall, it seems that she is gradually improving.
I hope you can maintain your confidence and continue to support her, as it is likely that her condition will slowly improve.
Reply Date: 2010/06/03
More Info
Post-surgery complications, particularly after gastric surgery, can be quite challenging to manage, especially in elderly patients with pre-existing conditions like diabetes and hypertension. In the case you described, your mother underwent a significant surgical procedure due to a perforated stomach, which inherently carries risks of infection, delayed recovery, and complications such as abscess formation.
Understanding the Situation
Your mother’s case is complicated by her age and underlying health issues. After the surgery, she experienced a decline in physical strength, poor bowel motility, and subsequently developed abscesses that required drainage. The persistent fever and muscle cramps suggest a possible ongoing infection or inflammatory response, which is not uncommon in post-operative patients, especially those who have undergone major abdominal surgery.
Managing Fever and Infection
1. Infection Control: The presence of abscesses indicates localized infection, which can lead to systemic symptoms like fever. It's crucial that the medical team continues to monitor her closely for signs of systemic infection (sepsis). Regular blood tests, imaging studies, and clinical evaluations should be performed to assess the effectiveness of antibiotic therapy and the need for further interventions.
2. Drainage and Surgical Intervention: If the abscesses are not resolving with conservative management (antibiotics and drainage), further surgical intervention may be necessary. This could involve re-exploration of the surgical site to ensure there are no residual infected tissues or new complications.
3. Supportive Care: Given her low energy levels and poor appetite, nutritional support is vital. The use of enteral feeding (like the nutritional supplements you mentioned) can help improve her overall health and immune function, which is crucial for recovery. Encouraging small, frequent meals that are easy to digest may also help.
4. Physical Rehabilitation: Engaging in physical therapy, even in a limited capacity, can help improve her muscle strength and overall recovery. This should be tailored to her current physical capabilities and gradually increased as her condition improves.
5. Monitoring for Thrombosis: The swelling in her thigh suggests a possible deep vein thrombosis (DVT), which is a serious complication that can arise from prolonged immobility. Compression stockings and anticoagulation therapy may be indicated to prevent further complications.
Communication with Healthcare Providers
It’s essential for family members to maintain open lines of communication with the healthcare team. Here are some suggestions on how to engage effectively:
- Ask Questions: Don’t hesitate to ask the doctors about the specific causes of her fever, the effectiveness of the current treatment plan, and what signs to watch for that may indicate worsening conditions.
- Request Regular Updates: Ensure that you receive regular updates on her condition, treatment progress, and any changes in her care plan.
- Advocate for Comprehensive Care: If you feel that her symptoms are not being adequately addressed, advocate for a multidisciplinary approach that may include infectious disease specialists, nutritionists, and physical therapists.
Conclusion
In summary, managing post-surgical complications like fever and infection requires a comprehensive approach that includes infection control, nutritional support, physical rehabilitation, and vigilant monitoring for complications. Given your mother’s complex medical history, it’s crucial to work closely with her healthcare team to ensure she receives the best possible care. Your involvement as a family member is invaluable in advocating for her needs and ensuring she has the support necessary for recovery.
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