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Neutropenic Sepsis
Clare Dikken
Macmillan Senior Chemotherapy Nurse
Sussex Cancer Network
Aims and Objectives
• To understand the terminology around neutropenic sepsis (NS)
• To identify signs and symptoms associated with NS
• To have a better understanding patho-physiology around NS
• To articulate how a patient with NS should be managed initially
Treatment of cancer
• Escalating use of cytotoxic therapy
• Used on a wide range of tumour sites
• Greater use in palliative care
• Increase in the number of lines of treatment
• Drug developments: monoclonal antibodies, small molecules3
Side effects
• Chemotherapy affects actively dividing cells
• It is not specific to cancer cells
• Results in a wide range of side effects
• Some can be life threatening
• Neutropenic sepsis is a life threatening side effect of chemotherapy
The neutrophil and neutropenia
• First line defence against bacterial infection
• Neutropenia = abnormally low neutrophil count
• Associated with an increased risk of potentially life threatening infection
• In general this is considered as a neutrophil count of < 1.0
• Measured by the absolute neutrophil count
• The nadir = 7-14 days post chemo• Neutropenic sepsis
Sepsis
• Sepsis is the clinical syndrome from SIRS• Inflammatory reaction results from infection• Micro-organisms invade the blood and
release toxins• Decrease tissue oxygenation is an important
physiological factor• Septic shock
SIRS
• Signs and Symptoms– Hypothermia or fever – Shaking or chills– Tachycardia– Hypotension – Tachypnoea
Sepsis
• Sepsis is the clinical syndrome from SIRS• Inflammatory reaction results from infection• Micro-organisms invade the blood and
release toxins• Decrease tissue oxygenation is an important
physiological factor• Septic shock
Term Definition
Infection Localised presence of infection
Bacteraemia Presence of viable bacteria in the blood
Systemic inflammatory response syndrome (SIRS)
At lease two of the previously mentioned conditions in response to clinical insult
Sepsis Presence of two or more SIRS criteria with infection
Severe Sepsis Sepsis with one or more signs of organ dysfunction
Septic Shock Sepsis with hypotension unresponsive to fluids
Bone et al 1992
Risk factors
Increased risk of septic shock
Neutropenia Age >65 or<1 yr
Corticosteroids and immunosuppressive therapy
Malignancy
Splenectomy
Chemotherapy
RadiotherapyMalnutrition
Hospitalisation
Antibiotic use
Breakdown of skin/mucous membrane
Invasive procedures
SOURCE OF INFECTION
Release of endo/exo toxins
IMMUNE RESPONSE
Recruitment of plasma cells; neutrophils,
macrophages, monocytes
Release of cytokines, proand anti-
inflammatory response mediators:e.g.
interleukins, nitric oxide, complement, platelet activating
factors, protaglandins etc
EFFECT ON BODY
Vasodilatation, endothelial inflammation,
increased vascular permeability,
decreased arterial and venous tone,
hypotension, myocardial depression
END POINT
End organ hypo-perfusion,
ischemia and cell death
Signs and Symptoms
Neutropenic sepsis
• Incidence: depends on drug regime, patient and duration of neutropenia
• Deaths are still occurring • Preventable deaths• Reason for deaths:
delay in getting into acute hospitaldelay in diagnosisdelay to first dose of antibioticneutropenic policy not being followed
• Many health professionals have never received any training or education on neutropenic sepsis
What can you do?
• Recognise at risk patients
• Recognise early and late presenting signs and symptoms
• Rapid referral to Acute services
• Use HEAT as a trigger
Patients at Risk
• Post chemotherapy 7-14 days• Haematology patients• Heavily pre-treated• Prior history of neutropenic sepsis• Breaches to the skin/mucous membranes• Co-morbid conditions e.g.advanced cancer• Poor general health • Elderly
What can you do?
• Recognise at risk patients• Recognise early and late presenting signs and
symptoms• Rapid referral to Acute services• Rapid diagnosis: FBC, blood cultures• Early intervention with appropriate treatment• Monitoring• Reporting
The HEAT Trigger
• H- History
• E- Examine
• A- Action
• T- Treat
Take home message
Patient on chemotherapy? Be suspicious
ACT FAST TO PREVENT DEATH
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