The crux lies in the definition itself – febrile neutropenia. This is the most important emergency as far as oncology training is concerned and oncology work is concerned. Febrile and neutropenia means fever and neutropenia. So how do you define fever? A single temperature of more than 101o or a temperature of more than 100.4o for one hour, that is fever. So a person who has a temperature of 101o or 100.4o for a period of one hour is febrile and neutropenia is an ANC, absolute neutrophil count, of less than 500 or a count which is going to fall to less than 500 in less than 48 hours. So to keep it simple, somebody who has fever and somebody who has a neutrophil count of less than 500, this is neutropenia.
There is a definition of profound neutropenia which we see in the leukemic patients, in the transplant patients, they are those patients who have a neutrophil count of less than 100. So that’s a profound neutropenia. Why do you need this definition? This is to identify the sickest of the sickest lot. So somebody who has an ANC of less than 100, we know they’re going to be sick so you’re going to be more careful with them.
What should nurses watch out for?
From a nursing point of view, again the most important thing is you have a cancer patient, the patient has recently received chemotherapy. Especially liquid tumours like AML inductions, transplant patients, solid tumours receiving high intensity chemotherapy like docetaxel, MVAC regimens, Adriamycin and cyclophosphamide regimens just to name a few, those who have not received prophylactic growth factors, elderly, frail, those who have comorbidities, these are the patients whom you will watch out for. I have an elderly comorbid gentleman or a lady who has any tumour, who has cancer who has received Adriamycin cyclophosphamide, no prophylactic growth factors, docetaxel, MVAC, leukemics, on induction, who receive high dose Ara-C, cytosine arabinoside, or transplant patients, if they come with fever the first diagnosis is going to be febrile neutropenia in the emergency room. So the first thing you are going to do is, again, airway, breathing, circulation, measuring their pulse, temperature and respiratory. Clinically you are going to classify these patients as low risk or high risk.
So what is a low risk or high risk? Somebody is walking, talking, coming into the emergency, fit, young guy, no comorbidities, solid tumour, has received growth factors, fever but blood pressure is fine, urine output is fine, mental status is fine, respiratory rate is fine, no tachycardia – they would qualify as low risk so you are not really worried about them. But somebody who comes in hypotension, hypoperfusion, seizures, altered mental state, coma, anuria, a leukemic patient or all those high risk patients which I mentioned, they are your high risk patients so you’ll immediately secure a line, as we’ve discussed earlier. You have a central line or a central portacath, or you will put an IV line in immediately. Check for airway, breathing and circulation. Watch for pleural overload but you will start aggressively hydrating if they are in hypotension. Obviously oxygenation.
You will immediately start them on empirical antibiotics pending cultures. This is the most important line we should emphasise to our nurses. You are going to send samples for your complete blood picture which will look at their neutrophil count, their haemoglobin, their platelet count. They’re going to look at renal function test, liver function test, ABGs, lactates. Then you send all this, despite it all, you’re going to do your blood cultures from two lines – one from your peripheral and one from your central aerobic and anaerobic. But despite all this you will empirically institute antibiotics, IV antibiotics, for your high risk patients. Because if you do not give antibiotics within the first sixty minutes, and some people say in the first thirty minutes, of FN the mortality is going to be very high. So you are going to stabilise, ABCs, put a line, send us labs, not wait for the labs, if you think it is high risk you will immediately give IV antibiotics.
What are the IV antibiotics? You can either give the carbapenems like meropenem or imipenem or cefepime or piperacillin-tazobactam or cefoperazone-sulbactam, any of these are okay. You will institute these and then you will follow up. Then the follow-up, basically, of changing antibiotics or antifungals or adding antifungals will be based on how the patient would eventually respond, maybe three to four days later. If the patient is responding, his is better, he is clinically getting better, his neutrophil count is on an upward trend, cultures are negative, he’s afebrile, we wouldn’t tinker with anything, we would continue the same antibiotics until the WBC goes up to 500, the ANC goes up to 500.
But if the patient is getting sicker by the third or fourth day you would start worrying. You would probably do a chest CT, you will do primary nodules, you will add antifungals. Or if the culture is different you will add the antibiotics based on your culture report.
Also one important thing to add is many a time our central lines which we put in could get infected. So we have to be very careful, from a nursing point of view, with handling our central line devices – constant flushing, constant, minimising multiple people using the central line. If the central line gets infected with pseudomona or candida or nontuberculous bacteria or the gram positive bacteria sometimes, then it would warrant a removal of the central line. So we have to be very, very, very careful.
What are your concluding messages for nurses?
The simple message to end would be if it is an emergency then we can get most of our patients with febrile neutropenia out of this critical condition just because of timely management. Nurses form the most important core in this because they would come to the ER. So timely institution of antibiotics within the first 30-60 minutes, number one. Sending two sets of cultures from the central and peripheral lines. The antibiotics which I have mentioned. Fluid resuscitation. Following up on your cultures is very, very, very important. Extremely important is hand hygiene – however much you overemphasise this is going to be less – very good hand hygiene is extremely important so that we don’t contaminate our patients’ lines, which is most, most important. Empirical gram positive cover is not required; we would add gram positive cover only if we have cultured positive bacteria. Each hospital has its own antibiotic policy so, based on your antibiotic policy, choose which antibiotic to be started empirically. And antifungals will be added – if you have pulmonary nodules you would add voriconazole; if we would have candida you would add amphotericin or caspofungin.
One thing which you would add is at the beginning, which I forgot to discuss, is all the patients with febrile neutropenia, we’re discussing all the high risk, would have a symptom directed imaging. That is, you would check with an X-ray or a CT for pneumonia; you would check for an abdominal scan for abscesses, for a source in the gut. You would do a routine urine culture if they had symptoms of urinary tract infection. Those patients who are in remission will require growth factor support.
Once the patients are afebrile, once the cultures are negative and the ANC goes above 500, I think we have crossed…