Oncologic emergencies (Proceedings)
THE SEPTIC NEUTROPENIC PATIENT:
otherapy patient that is not feeling well should have a CBC performed, as well as a thorough physical examination. Severely neutropenic patients may not have enough leukocytes to mount a febrile response. Chemotherapy- induced neutropenia generally happens 7-10 days after administration although the range can extend from 4-16 days. Chemotherapy induced death of in intestinal crypt cells occurs on day 2-5 resulting in potentially higher numbers of enteric bacteria crossing the intestinal epithelium. Neutrophil numbers may not be sufficient to clear infection and multiple organs can quickly become involved. Neutrophil numbers <1,000/ul leave them at increased risk, and numbers <500/ul are almost a guarantee.
Baseline evaluation should include physical examination, CBC, biochemical profile, urinalysis and possibly blood and urine cultures and thoracic radiographs. These cases when treated aggressively have a good prognosis. Without treatment their prognosis is very guarded. They should be hospitalized and receive intravenous fluids and antibiotics.It is important to rehydrate these patients quickly. Intravenous fluids alone will often start to bring the temperature down and make them feel much better. This will also help protect the kidneys from any potential nephrotoxicity secondary to cephalosporin or aminoglycoside administration by ensuring they are well hydrated. Cultures most often return a diagnosis of strep, staph, or a variety of gr- enteric bacteria. A first generation cephalosporin and an aminoglycoside will effectively treat over 95% of these patients. When treated effectively their temperature should start approaching normal by 8-12 hours after instituting therapy. We generally recommend taking their temperature every 1-2 hours in the initial phases of treatment. Their hydration status, blood glucose, electrolytes and blood pressure should also be evaluated multiple times each day. Patients receiving aminoglycoside antibiotics should also have urine sediments examined daily.
In patients with underlying renal disease, a second generation cephalosporin along with a fluoroquinolone can be considered. These patients may take longer for their body temperatures to return to normal. Approximately 5% of cases have anaerobes involved in their etiology and the addition of metronidazole would be required. The benefit of G-CSF is well documented in the prophylactic setting. It is more controversial in the febrile patient, but there is little drawback to adding it to the treatment regimen. Once the patient has been afebrile for a full 24 hours, and their neutrophil count is >1,000/ul they can return home on oral antibiotics which should be administered for another 5-7 days.
The data base for these patients should include a physical examination (including rectal palpation), CBC, biochemical profile, urinalysis +/- thoracic and abdominal radiographs and abdominal ultrasound. Calcium values >14 mg/dL are an indication for treatment, at 16-18 mg/dL they are considered critical patients and those >18 mg/dL are at risk for a crisis.
The goal of therapy is to increase renal excretion and decrease absorption of calcium, without compromising your ability to diagnose the primary etiology. The mainstay of treatment is intravenous fluid administration. Normal saline is the treatment of choice as it will maximize calciuresis. Fluid rates 2-3 times maintenance may be required to keep up with their losses and rehydrate the patient adequately. Other treatment options include furosemide, bisphosphonates, calcitonin and prednisone. Try not to use the prednisone until all diagnostic samples are collected so that a lymphoma is not masked. The best treatment by far is to diagnose the primary etiology and treat it appropriately.