NEUTROPENIC SEPSIS

1
NEUTROPENIC SEPSIS
2
Neutropenic sepsis is a medical emergency and can
be frightening!
17 year old former soldier 1st cycle chemo for
neuroblastoma 8 days ago
10.00 am OK during breakfast 11.00 am Found
collapsed on the floor in her bathroom 1.00 pm
Brought into hospital moribund 3.00 pm Cardiac
arrest in the lift whilst being transferred to
ITU. Futile CPR
3
Definition

• Neutropenia Neutrophil (Granulocyte) count lt1.0
  x109/L
• Febrile Neutropenic Neutropenia with a sustained
  (gt1hr) temperature greater than 38oC, but
  cardiovascularly stable
• Neutropenic Sepsis Neutropenia with sustained
  pyrexia and any cardiovascular compromise
  (tachycardia, hypotension, tachypneic)

4
(No Transcript)
5
(No Transcript)
6
Regimen dependent

• Some are more myelosupressive than others
• BEP for testicicular cancer up to 20
• R-CHOP (Non Hodgkin Lymphoma)
• FEC-T (Adjuvant breast)
• All chemotherapy can cause neutropenia
• Xeloda (Capecitabine)
• oesophagus, bowel, breast
• Neutropenia not as common but when assocaited
  with colitis (typhlitis) can be deadly

7
Presentation

• Patients can present in a spectrum of situations
• Very well, no suggestive infection symptoms
  except pyrexia to moribund!
• Patients can deteriorate rapidly as essentially
  they have no immune system
• THEREFORE NEUTROPENIC SEPSIS IS A MEDICAL
  EMERGENCY

8

• PROMPT ACTION CAN SAVE LIVES
• MANY PATIENTS NOW HAVE CURABLE DISEASE
• BE AWARE OF THE NON-FEBRILE NEUTROPENIC (long
  term steroid use)
• ANY DOUBTS ASK SENIORS/SpR/CONSULTANTS

9

• CONSIDER NEUTROPENIA IN ANY SICK PATIENT WHO HAS
  HAD CHEMOTHERAPY RECENTLY

10
Symptoms

• Fever temp gt 38C
• Vague non-specific symptoms - ?muscle aches/flu
  like symptoms
• Any other symptoms suggestive of infection
• Drowsiness
• ALWAYS ASK OF PREVIOUS NEUTROPENIC EPISODES
  HIGHER RISK PATIENTS

11
Signs

• Pyrexia temp gt 38C
• Tachycardia
• Drowsiness
• Signs of infection infected lines (PICC,
  Hickman), wounds?
• HYPOTENSION OMINOUS SIGN- URGENT ATTENTION DO
  NOT KEEP IN SIDE ROOM, HDU/ITU.
• Early warning to ITU outreach team

12
Investigations

• FBC (urgent with differential)
• Blood cultures central and peripheral
• Urine cultures
• Swabs lines, wounds
• U E, LFT, Clotting
• CXR
• ABG consider for lactate high poor sign

13
Management
Dont wait for FBC In an unwell patient start
IV Antibiotics as protocol
14
Management

• Good iv access (green venflon)
• Prompt Abx
• IV fluid (stat if hypo-tensive)
• If hypotensive should consider catheterisation
  to monitor urine output good guide to adequate
  resuscitation
• Sick patients should be seen by SpR/consultant
  frequently to assess the need for escalation of
  management

15
Further Considerations

• GCSF Consider in patients who are profoundly
  septic/neutropenic
• Also consider for future chemotherapy cycles
• Dose reduction (palliative chemo)
• Prophylactic GCSF (curative/adjuvant)
• ?stop treatment

16
SUMMARY

• Can occur any time post chemotherapy
• Full thorough assessment
• Start antibiotics early dont wait for bloods
• Door to needle 1hr
• Please watch the following DVD