Commentary—Postoperative Fever in Children Hospitalized After Surgery: Incidence and Risk Factors

The comanagement of surgical patients by pediatric hospitalists is a common practice at many institutions; however, precise data on how such programs are structured, including details of interdisciplinary agreements, operations, staffing, and financial support, are limited.1,2 Goals of pediatric hospitalists’ involvement in perioperative care of pediatric patients include optimizing patients’ preoperative clinical status, standardizing perioperative care, and addressing acute medical issues that arise during hospitalization, such as postoperative complications.3 Comanagement models offer a framework for collaboration between hospital medicine and surgical services, particularly as both specialties care for an increasing number of children with chronic conditions who require surgery.4–7 Pediatric hospitalists and surgeons caring for children, especially those with medical complexity, need to be well-versed not only in perioperative issues but also in shared decision-making, interdisciplinary communication, discharge planning, and high-value care. Any new data on perioperative care and outcomes for children undergoing surgery are highly valuable to both the surgical and hospitalist communities. In this issue of Hospital Pediatrics,8 Hong et al contribute to this literature by providing important data on risk factors associated with postoperative fever (POF) in pediatric patients.POF is common in pediatric patients, and previous retrospective studies, mainly conducted at single centers, have shown significant variability in both POF incidence rates and how often pediatric patients undergo evaluation to determine the etiology of POF. Initial evaluations often involve broad diagnostic workups—such as blood cultures, urine studies, and chest x-rays—that are typically low yield and sometimes prolong hospitalization.9,10 These studies have analyzed surgical, anesthesia-related, and patient-specific risk factors for POF, as well as the degree, persistence, and frequency of fever.The article by Hong et al in this issue of Hospital Pediatrics8 enhances our understanding of POF and its associated risk factors, including patient age, nutritional status, and, for the first time in a study of this kind, medical complexity. The authors defined POF as a temperature of 38.0 °C or higher recorded within the first 7 days after an elective surgery. Risk factors were divided into 2 categories: procedure-specific (type, duration, and the presence of multiple surgical specialties) and patient-specific (sex, age, insurance, race/ethnicity, weight, and the number of chronic conditions). The study analyzed 35 030 surgical encounters involving 27 637 patients, with 205 procedures performed. Tonsillectomy/adenoidectomy, spinal fusion, bone fixation, and therapeutic heart procedures were the most frequently performed surgeries, with a median procedure duration of 2.8 hours. Patients had a median of 3 body systems affected by chronic medical conditions, and the median postoperative hospitalization duration was 2.9 days. The incidence of POF ranged from 8.1% in ophthalmologic procedures to 35.2% in cardiovascular surgeries, and surgeries longer than 6 hours were more likely to be associated with POF. Among procedure types, patients who underwent nonendovascular valve procedures, kidney transplants, and hepatobiliary resections/ablations had the highest POF rates. In terms of patient-specific factors, children aged 1 to 4 years, those with lower weight, and those with more than 5 chronic conditions experienced the highest rates of POF. Consistent with prior reports, most fevers occurred between postoperative day 0 and 1 and lasted less than 48 hours.These data are valuable for surgical teams, hospitalists, patients, and their caregivers as they prepare for the postoperative period. Knowing that 1 in 5 patients may develop POF is a helpful data point that may reduce unnecessary workup and anxiety. Younger age, lower weight, and a greater number of chronic conditions increase the likelihood of POF, even after controlling for surgery duration, as expected. For the first time, patient stratification by the number of chronic conditions was included in the description of POF. This contribution to literature enables pediatric hospitalists and surgeons to consider medical complexity when assessing POF, thereby clearly distinguishing between those with and without chronic conditions.Interpreting the data from Hong et al’s study requires aligning it with existing knowledge regarding children with medical complexity. Children with medical complexity have higher rates of infections than those without, although the reasons remain unclear.11,12 Poor nutritional status particularly affects children with chronic conditions and may be associated with increased surgical complications, including a higher risk of infection, longer hospital stays, re-operations, increased costs, transfusion needs, and perioperative mortality.13–18 Although Hong et al did not directly measure patients’ nutritional status, low weight may serve as a proxy for poor nutrition. Recognizing that patients with low weights have higher rates of POF and may also be at higher risk for true infections can complicate postoperative evaluations of patients that are underweight, particularly those with medical complexity.Although not specifically mentioned in the Hong et al study, we believe that standardizing the approach to POF can improve patient-centered perioperative care. The concept of Enhanced Recovery After Surgery (ERAS), a patient-centered, evidence-based, multidisciplinary, and multimodal approach designed to minimize surgical stress, maintain physiological function, and improve postoperative recovery, is relevant here.19 This study’s findings offer an opportunity to develop standard guidelines for children undergoing surgery based on the ERAS principles. ERAS guidelines could include recognizing that POF is more commonly observed on postoperative days 0 to 2 and is rarely associated with bacterial infections during this period. High-value care principles could further emphasize the even lower risk for postoperative infections among certain groups, such as older children, those undergoing shorter procedures, those with healthy weight parameters, and those with fewer than 5 chronic conditions. This recognition could help clinicians tailor evaluation and management of patients with POF more effectively.Limitations of the study by Hong et al include significant loss to follow-up, mainly due to numerous early discharges before postoperative day 7. Although some clinical data were captured through subsequent health care encounters, these early discharges hindered the collection of consistent outcomes and may have led to data fragmentation. Additionally, some of the most medically complex patients may have been excluded because they were hospitalized preoperatively, potentially leading to an underestimation of the risk of POF in this population. Although the authors reported patients’ overall medical complexity, additional details on specific preexisting conditions (such as obstructive sleep apnea, chronic respiratory failure, dependence on medical technology, and others) would enable a deeper understanding of condition-specific risk factors for POF. Finally, the study’s generalizability is limited by the single-center design with well-developed, well-supported complex care and surgical comanagement programs and the predominance of privately insured patients, which may limit generalizability to other institutions.Hong et al’s study provides important data to help guide hospitalists, surgical teams, and families as they approach pediatric surgery, specifically the common challenge of POF. Future directions point toward a multicenter study with more detailed stratification by chronic condition and a description of granular diagnostic workup modalities, with comparisons of their associated outcomes and costs.