Oncological emergencies Flashcards
define febrile neutropenia
an oral temperature of 38.5 degrees C or more, or 2 consecutive readings of 38 degrees C or more for 2 hours, AND an absolute neutrophil count of 0.5X10^9/L or less.
infection responsible for at least half of cases
often no causative organism found-better prognosis, and pt improves as neutrophil count increases
when is febrile neutropenia most often seen?
neutrophil count usually reaches its lowest level 5-10 days after last dose of chemotherapy.
why might a patient having chemotherapy develop neutropenic sepsis but NOT have a fever?*
as pt immunocompromised, there may not be the normal immune response that would cause a rise in temperature
therefore neutropenic sepsis diangosis: pt having anti-cancer treatment with neutrophil count 0.5X10^9/L or less and have either temp higher than 38C, or other signs and symptoms consistent with clinically significant sepsis.
why is early recognition of neutropenic sepsis vital?
deterioration can be rapid and fatal, mortality rate range between 2% and 21% in adults
which patients are at risk of neutropenic sepsis?
those receiving chemo-often 5-10 days after last tment
those receiving extensive field radiotherapy
those with haematological conditions assoc. with neutropenia: leukaemia, lymphoma, myelodysplasia
other causes: non cancer drug related e.g. clozapine, carbimazole, phenytoin, chloramphenicol, infections, hereditary-physiological, autoimmune e.g. felty’s syndrome-RA, splenomegaly, neutropenia.
common organisms involved in neutropenic sepsis?
usually endogenous flora
increasing incidence of gram +ve cocci: staph aureus, staph epidermidis, strep pneumoniae, strep pyogenes, strep viridans, enterococcus faecalis, gram +ve bacillus-corynebacterium
gram -ve: E coli, pseudomonas, klebsiella
fungal infection-candida
what do we want to know in the hx of a pt presenting with suspected neutropenic sepsis?
general symptoms: fever, drowsy, confused
those suggesting underlying infection source: cough, SOB, ENT, dysuria, vomiting, diarrhoea, skin, central line
co-morbidities
Ca type, stage, prior tment and date of last treatment, number of days since last chemo
other drugs: Abx, drugs known to cause neutropenia
signs to examine for in patient with likely neutropenic sepsis?
febrile
tachycardia
hypotension-involve outreach, consider escalation above ward care e.g. ITU admission
dehydration
mouth ulcers
signs of infection: central lines, skin wounds/soft tissue, ENT, chest-creps, SOB, sputum-culture
drowsy, impaired MMSE
investigations to aid initial clinical assessment of pt with likely neutropenic sepsis?
FBC including differentials U+Es, renal profile LFTs, including albumin CRP-note often lags, rise at 48hrs, monitor trend, can be raised in Ca aswell lactate blood culture
further investigations after initial assessment investigations have been performed for neutropenic sepsis?
MSU-culture
stool culture
CXR IF clinically indicated e.g. px cough
clotting-need to assess for DIC-prolonged APTT, decreased fibrinogen, increased FDPs, low PLTs
swabs of lines and wounds
ABG
imaging directed clinically-AXR, CT/MRI-CT abdo if worry about fistulae
NICE recommended empiric ABx therapy for neutropenic sepsis?
IV tazocin (tazobactam and piperacillin) within 1 hour!-given 6hrly (QDS) by IV infusion
if allergy, consider meropenem
if cross reactivity, consider ciprofloxacin (quinolone)
management other than empiric IV broad spec Abx to consider in neutropenic sepsis?
fluid resuscitation
consider catheterisation
consider additional anti-fungal coverage in high risk pts who remain febrile after 3-7 days of BS Abx and no identified causative organism
involve senior team members-SpR and consultant
consider need for care escalation
G-CSF-consider if profoundly septic/neutropenic, may be given prophylactically for future chemo cycles-often given in breast Ca patients having adjuvant treatment, may consider chemo dose reduction if palliative, or stopping the treatment all together.
ensure patients and their carers educated on neutropenic sepsis and how and when to contact 24hr specialist oncology advice and seek emergency care.
give examples of 3 different mechanisms behind SC compression in cancer patients?
extradural spread of a vertebral body metastasis e.g. breast, thyroid, lung, kidney or prostate Ca metastases
or from haematological tumours e.g. multiple myeloma and non-hodkin’s lymphoma
direct metastases e.g. bladder, renal, breast
vertebral crush fracture
importance of a whole spine MRI in investigation of metastatic spinal cord compression?
more than 50% have more than 1 area involved
most common spinal location for metastatic disease?
thoracic spine
which tumours commonly metastasise to bone?
thyroid breast lung kidney-most common metastasis site=lung prostate-note that if pt metastasis of prostate Ca to sites other than bone e.g. lung is very uncommon, bone=most common.
clinical symptoms of metastatic SCC?
back pain-spinal, radicular, worse on coughing and straining, nocturnal pain, spinal tenderness
weakness-difficulty walking, lower limbs giving weigh
sensory disturbance-paraesthesia, anaesthesia
autonomic disturbance-urinary retention, constipation/faecal incontinence
investigations for metastatic SC compression?
MRI WHOLE SPINE
consider targeted CT with 3 plane reconstruction to assess spinal stability and plan vertebroplasty-cement put into the vertebra, kyphoplasty or spinal surgery
myelography-contrast injection in to space around SC and spinal nerve roots
timescale for definitive treatment of metastatic SCC?
24hrs
indications for bisphosphonate treatment to relieve pain in patients with vertebral metastases?
offer to reduce pain and risk of vertebral fracture/collapse when vertebral involvement with breast Ca or myeloma
use to reduce pain in prostate Ca mets only if other analgesia failed
indication for radiotherapy treatment of spinal metastases?
offer 6 Gy single fraction palliative radiotherapy to those with spinal mets causing non-mechanical spinal pain.
treatment of metastatic SC compression?
dexamethasone-at least 16mg PO or IV, give as stat and then 8mg BD with gastroprotection
after surgery e.g. with bone grafting, or start of radiotherapy, should reduce steroid dose gradually over 5-8 days and stop, ensure blood glucose levels monitored whilst on steroids
radiotherapy for definitive treatment-urgent if unsuitable for spinal surgery unless complete tetraplegia or paraplegia for more than 24hrs and pain well controlled, or overall prognosis judged to be too poor.
give post op fractionated radiotherapy to all if satisfactory surgical outcome, once wound healed
offer fractionated as definitive tment if epidural tumour without neurol impairment, mechanical pain or spinal instability.
