Septic shockneutropenic fever

One of the commonest haemato-oncological emergencies.

• May be defined as the presence of symptoms or signs of infection in a patient with an absolute neutrophil count of <1.0 x 109/L. In practice, the neutrophil count is often <0.1 x 109/L.

• Similar clinical picture also seen in neutrophil function disorders such as MDS despite normal neutrophil numbers.

• Beware —can occur without pyrexia, especially patients on steroids.

Immediate action

►► Urgent clinical assessment.

• Follow ALS guidelines if cardiorespiratory arrest (rare).

• More commonly, clinical picture is more like cardiovascular shock ± respiratory embarrassment viz: tachycardia, hypotension, peripheral vasodilatation and tachypnoea. Occurs with both Gram +ve (now more common with indwelling central catheters) and Gram -ve organisms (less common but more fulminant).

• Immediate rapid infusion of albumin 4.5% or Gelofusin to restore BP.

• Insert central catheter if not in situ and monitor CVP.

• Start O2 by face mask if pulse oximetry shows saturations <95% (common) and consider arterial blood gas measurement—care with platelet counts <20 x 109/L—manual pressure over puncture site for 30 mins.

• Perform full septic screen (see guidelines on IV antibiotics, p552).

• Give the first dose of first line antibiotics immediately e.g ureidopeni-cillin and loading dose aminoglycoside (ceftazidime or ciprofloxacin if pre-existing renal impairment). Follow established protocols.

• If the event occurs while patient on first line antibiotics, vancomycin/ rnn ciprofloxacin or vancomycin/meropenem are suitable alternatives.

• Commence full ITU-type monitoring chart.

• Monitor urine output with urinary catheter if necessary—if renal shutdown has already occurred, give single bolus of IV frusemide (furosemide). If no response, start renal dose dopamine.

• If BP not restored with colloid despite 4 CVP, consider inotropes.

• If O2 saturations remain 5 despite 60% O2 delivered by rebreathing mask, consider ventilation.

• Alert ITU giving details of current status.

Subsequent actions

• Discuss with senior colleague.

• Amend antibiotics according to culture results or to suit likely source if cultures negative (see p554, 556).

• Check aminoglycoside trough levels after loading dose and before second dose as renal impairment may determine reducing or withholding next dose. Consider switch to non-nephrotoxic cover e.g ceftazidime/ciprofloxacin.

• Continue antibiotics for 7-10d minimum and usually until neutrophil recovery.

• If cultures show central line to be source of sepsis, remove immediately if patient not responding.

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