Febrile Neutropenia

Question 1

A 6 year old girl has acute lymphoblastic leukaemia. She is in the early phase of treatment with relatively aggressive chemotherapy. She presents to her local emergency department with fever and lethargy, but no obvious site of infection.

Answer 1

Impression
I am concerned that this patient has developed a neutropenic sepsis given the fever in the context of intercurrent chemotherapy for ALL. This is a medical emergency and needs to be treated on an emergent basis.

DDx
- consider sites of infection; resp, urine, skin, GI, lines/catheters
- opportunistic infections (fungal, parasitic)

Goals
- MERT call, rapid A to E assessment, intervene for any Hd instability and administer empirical ABx therapy with piptaz +/- further agents
- targeted Hx/Ex/Ix to determine underlying cause
- Alert treating haematologist, consider ceasing chemotherapy - EMERGENCY

Question 2

Febrile neutropenia - Assessment

Answer 2

Assessment
- call for senior help
- Conduct
A - patent, maintaining
B - CXR as part of septic screen, sputum MCS
C - HR/BP monitoring. IVC access if not already achieved, initial bloods: FBC (neutropenia), VBG, CRP, UEC, Cultures, coags). Administer fluid resus at 20ml/kg bolus then additional as required. Start empirical ABx for neutropenic sepsis:
o IV Piptaz + Amikacin (given ALL) +/- Vanc, consider adding Gent/amp/metro if ?GI source, Vancouvers if suspected MRSA

D - neuro assessment
E -

Question 3

Febrile Neutropenia - History

Answer 3

History
- PC: fevers, chills, sweats, malaise, rigors. localising sx( abdo pain, bowel/urinary features, respiratory, headaches, skin rashes, etc)
- HPI: chemotherapy, what on, when started, previous infections?
- Paeds: development, pregnancy/birth, vaccination status
- Check the febrile neutropenia card from the haematologist

Question 4

Febrile Neutropenia - Examination

Answer 4

Examination
- General appearance + vitals
- Systems review; rule out severe systemic infection, look for localisation if no HD instability.

Question 5

Febrile Neutropenia - Investigations

Answer 5

Investigations
Key
- septic work up

Other
- Bedside: UA
- Bloods: as per A to E assessment

Question 6

Febrile Neutropenia - Management

Answer 6

Management
Definitive;
- as per A to E
- consult with Haematology/oncology regarding continuing treatment for ALL
o consider GCSF administration
- continue ABx for 72 hours then reassess
- regular observations
- if still febrile consider further investigations