Acute Oncology Guidelines
- Take thorough history, including systemic enquiry, looking for potential infection source.
- Perform a meticulous and well documented physical examination, including mouth, sacrum and perineum as well as examining any peripheral or central lines.
Febrile neutropenia management pathway: important notes and management
Warning
Febrile neutropenia management pathway
Patients can deteriorate rapidly – If NEWS ≥5 or 3 in one parameter:
Medical review (FY2 or above) required within 20 mins. If initial management cannot be completed within 1 hour, it is the responsibility of the FY1/2 contacted to seek support. Nursing staff should escalate above FY1/2 if no medic available within timelines or if they are unhappy with medical management planned.
Escalate to the On Call SpR (Ask for on-call registrar via switch) or On Call Consultant if required.
*Sepsis: Pyrexial – temperature >38oC or clinically unwell even if apyrexial. Symptoms and signs may include sweats, chills, rigors, malaise, tachypnoea >20/minute, tachycardia >90bpm, hypotension, evidence of cellulitis, gastroenteritis, UTI, signs of at least one acute organ dysfunction, e.g. hypotension, confusion, oliguria, raised serum lactate. Patient may appear well perfused despite hypotension.
***Septic shock: Sepsis induced hypotension that is unresponsive (within 1 hr) to adequate fluid resuscitation (i.e. systolic BP <90mmHg; reduction of >40mmHg from baseline; hypotension requiring inotropic support). Patients with septic shock should usually be discussed with HDU/ITU team.
- Imaging: CXR (don't delay antibiotic therapy for trips to Radiology. Unwell patients must be escorted)
- Midstream specimen of urine (MSU) - take urine culture but don't delay antibiotic therapy if micturition is not immediately possible.
- Stool culture if diarrhoea.
- If productive cough, send sputum for bacterial culture.
- Viral throat swab.
- Swab of line site, and any areas of broken skin.
- If atypical pneumonia suspected, sputum for bacterial culture, legionella PCR, fungal culture and PCR for viruses and mycoplasma. When pneumocystis jirovecii is suspected please send induced sputum or bronchoalveolar lavage (BAL) and telephone the laboratory.
- Chase FBC result. If neutropenic at <1, calculate MASCC score and CISN score (see Outpatient management of low risk adult oncology patients with febrile neutropenia) to assess suitability for outpatient management with oral antibiotics.
- If MASCC score <21, or CISN score >3, or other clinical concern, patient to remain inpatient.
- Choose ongoing antibiotic regimen (see Antibiotic management of neutropenic sepsis or febrile neutropenia in adult oncology patients in the Edinburgh Cancer Centre)
- Consider G-CSF. If febrile and any of the following applies. Give daily GCSF until neuts >1 for 2 consecutive days:
- Neutrophil count <0.1x109/L
- Hypotension (>20mmHg below normal systolic BP, not responding to fluid challenge)
- Multi-organ dysfunction (sepsis syndrome)
- Pneumonia or invasive fungal infection.
- Predicted neutropenia >10days (usually haem regimens)
N.B. Discuss with consultant regarding G-CSF if patient has active Covid-19 infection or lung inflammation/infiltrates.
- G-CSF dosing: Filgrastim 300micrograms once daily if <80kg, 480 micrograms once daily if >80kg.
- If patient does not pass urine for 3 hours consider catheterisation.
- Withhold ACE-i, ARBs, NSAIDs, diuretics, metformin.
- Consider adrenal insufficiency. If ≥3 high-dose oral glucocorticoids in last 12 months (incl post-SACT antiemetic dexamethasone of 4mg BD for 3 days) or prolonged (>10 days) course of dexamethasone (≥6mg daily) or non-cancer related use of high dose inhaled or topical glucocorticoids - consider giving 100mg hydrocortisone IV. Consider following with either infusion of hydrocortisone 200mg IV over 24 hours, or 50mg hydrocortisone IM/IV four times daily.
- If blood glucose abnormal on admission, ongoing monitoring of blood sugars (BMs)
- Daily bloods: FBC, U&Es, LFTs and CRP.
- Whilst febrile, daily blood cultures (peripheral and central)