BopaIntrocases by

Case patient 1, part a

bruce_burnett1 — 2020-06-14 17:23:17 UTC

Background:
•Patient AB

•10 days post-EOX (epi, oxali, capecitabine), cycle 3 of planned 8

•Still completing capecitabine

•54 years old

•No co-morbidities of note

•Penicillin allergy (confirmed allergy)

Case Patient 1, part a questions

bruce_burnett1 — 2020-06-14 17:24:45 UTC

Answer the following questions. Click the + in the next column to create a note and add your answers using YOUR LOCAL PROTOCOL.

•What symptoms would require consideration of management of neutropenic sepsis?

•How would it be confirmed? (tests)

•Which antiinfective(s) would be prescribed?

•What timescale is stated for administration to begin within?

Case patient 1, part b

bruce_burnett1 — 2020-06-14 17:31:02 UTC

Further information for patient 1:

•Admitted after completing 8th (final cycle) of EOX

•C/O weakness, nausea, polyuria and thirst

Case patient 1, part b

bruce_burnett1 — 2020-06-14 17:32:59 UTC

•What is the most likely cause?

•What blood tests should you perform?

•What should you monitor?

•What treatment would you provide?

Background

bruce_burnett1 — 2020-06-14 17:52:32 UTC

•48 year old Small Cell Lung Cancer

•No comorbidities

•Newly diagnosed, bulky disease

Case patient 2, part a

bruce_burnett1 — 2020-06-14 17:53:38 UTC

Answer the following questions. Click the + in the next column to create a note and add your answers using YOUR LOCAL PROTOCOL

•Does this patient require tumour lysis syndrome prophylaxis?

•If the patient required treatment, what would you recommend (be precise!)

Background

bruce_burnett1 — 2020-06-14 17:56:02 UTC

Further information for patient 2:

•Routine blood test now shows sodium level to be 129 mmol/L

Case patient 2, part b

bruce_burnett1 — 2020-06-14 17:57:39 UTC

Answer the following questions. Click the + in the next column to create a note and add your answers using YOUR LOCAL PROTOCOL

•How would you manage this patient?

•Which medication would you recommend? – be specific (dose, frequency etc.)

Symptom for neutropenic sepsis - sweats, chills or rigors

2020-06-19 10:14:23 UTC

How neutropenic sepsis confirmed

2020-06-19 10:15:00 UTC

Blood test neutrophils<0.5x10/l and NEWS score greater than or equal to 5 (temp greater than 38 or less than 36), resp rate>20/min, tachycardia >90bpm, systolic BP<90mmHg, blood glucose>6.6 (absence of diabetes), WCC>12 or <4, acutely altered mental state

Antiinfective to be prescribed

2020-06-19 10:15:22 UTC

Note Penicillin allergic therefore ciprofloxacin 400mg IV plus vancomycin IV plus gentamicin V plus/minus metronidazole 500mg IV (if anaerobic infection suspected e.g. intra-abdominal sepsis

Timescale

2020-06-19 10:17:12 UTC

Antibiotics to be started within ONE hour of triage

2020-06-22 20:37:43 UTC

Rachel Workman
Pyrexial >38, fever, sweat, malaise, resp rate >20, tachycardia >90, hypotension

Confirmed with neutrophils <1, raised serum lactate

Treat within 1 hour. If anaphylaxis pen allergy then IV cipro 400mg 12 hourly, IV gent, IV vanc. If pen allergy not anaphylaxis then IV aztreonam 2G 6 hourly, IV gent, IV vanc

guidelines = Bucks Healthcare Trust Neutropenic sepsis

qiratulainkhan — 2020-06-23 12:11:44 UTC

Symptoms =temp above 38 degrees or have signs of clinically significant sepsis i.e. rigor, feeling unwell, flu like symptoms- within 6 weeks of SACT

Patients are given a Neutropenic Sepsis Alert and Emergency prescription card on their first cycle chat - this alows them to recieve IV treatment within 60 minutes of presenting to hospital - the card itself is a prescription.

Sepsis would be confirmed with an FBC where neutrophils are <0.5 (or <1.0 with an expectation to fall further), and with symptoms.

Generally antibiotics given on the emergency card are a stat dose of Piperacillin/tazobactum 4.5g IV 8 hourly, or in penicilin allergy Meropenum 1g 8hourly.

Following this they would obtian cultures and change as appropriate or if no cultures and symptoms do not improve after 48 hours then to ad other agents.

Symptoms of neutropenic sepsis :

2020-06-24 08:37:31 UTC

Temperature 38C for 1 hr, or Temperature of 38.5C on one occasion with neutrophil count..1x10 9ft.
Significant deterioration in clinical state, development of rigors , or shock ( systolic BP...90 mmHg or a drop of ..50mmHg in hypertensive patients).
Signs of infection suggesting involvement of respiratory tract, urinary tract, or central venous catheter /Hickman line..
*Test that would confirm this , investigations :
*FBC
*Differential WBC
* Blood cultures
*MSU/CSU
* U&E
*Appropriate swabs (eg, Throat, Mouth, Wound, Hickman line exit site, if appropriate).
*Chest X-ray if chest signs and/ or Sa02 <92% on air.
* If GI symptoms (eg .Diarrhoea and abdominal pain) send stool sample for * Culture sensitivity and Clostridium Difficile toxins.

*Anti-invectives that would be prescribed for patient with Penicillin allergy but no history of anaphylaxis : Meropenem, 1g IV 8 hourly alone. If however the patient has a Hickman line( central venous catheter ,then Vancomycin can be added.

2020-06-24 08:49:54 UTC

Symptoms and signs include:

Temp 38C for an hour or temp above38.5 on one occasion and with neutrophils count <1 x10 9fl
Shock : systolic <90 or drop of >50 in hypertensive
Signs of infection suggestion involvement in resp tract, urinary tract or central venous catheter/hickman line

Test needed:
FBC
Diffential WBC
BLOOD CULTURES
MSU/CSU
U&E
Swabs
Chest extant if signs SAO2 <92 on air
If GI symptoms SEND STOOL SAMPLE
culture/sensitivity and c. diff toxins.

2020-06-24 08:58:04 UTC

2020-06-24 09:04:01 UTC

Immediately

2020-06-24 09:19:40 UTC

Urine infection? Do FBC WBC u&e, monitor temp and signs of septic shock. trimethoprim

* Symptoms of patient for consideration of neutropenic sepsis management are:

annchrismas — 2020-06-24 10:02:19 UTC

Temperature 38c for 1 hour or temperature >38.5C on one occasion with neutrophil count <1 X 10 9FL
* Significant deterioration in clinical state.
*Signs of infection suggesting involvement of respiratory tract, urinary tract and Hickman line exit site.

TEST TO CONFIRM:
Using appropriate swabs for , throat, mouth and at Hickman line site.
Test : FBC-(Full blood count).
Differential WBC( white blood cells).
MSU/CSU( mid stream urine-Catheter specimen urine.
U & E
CHEST X-RAY
If GI symptoms (Eg DIARRHOE abdominal pain) send stool sample.

ANTINFECTIVES THAT WOULD BE PRESCRIBED FOR PATIENT WITH PENICILLIN ALLERGY-Meropenem 1g iv 8 hourly alone 8 hourly timescale.

rendosy3 — 2020-06-24 10:02:23 UTC

Symptoms:
-Temp of 38C for 1hr or >38.5 on one occasion with neutrophil count <1 x 10 9fL
-détérioration in clinical state: shock ( systolic no <90 or a drop of >50mmhg in hypertensive
-signs of infection from respiratory tract, urinary tract or central venous catheter/Hickman line

rendosy3 — 2020-06-24 10:09:10 UTC

rendosy3 — 2020-06-24 10:10:52 UTC

UTI? FBC WBC U&E ,BP, TEMP AND PULSE. Trimethoprim Bd 7-14 days

As increased urine output.

annchrismas — 2020-06-24 10:31:27 UTC

Could be a UTI. Test carried out would be - DIP STICK , URINE TEST FIRST THEN FULL BLOOD COUNT .

Q1 & Q2 on opposite page.

annchrismas — 2020-06-24 10:35:31 UTC

Q3 What should you monitor?
*BP, Temperature & Pulse.
TREATMENT PROVIDED WOULD BE -:MALE 7 DAYS and FEMALE 3 DAYS , unless neutropenic, then a longer course.

rendosy3 — 2020-06-24 10:36:34 UTC

rendosy3 — 2020-06-24 10:38:30 UTC

We usually follow the Sussex county protocol if the need arise, Londoncancer.com suggest prophylaxis due to bulk. Depending on assessment results allopurinol 300md OD. 24 hrs prior to chemo adjusted for renal Function

Symptoms to consider: Temperature over 38 degrees with symptoms, low neutrophils of 0.5- 0.9

2020-06-24 10:53:26 UTC

Confirmation by blood tests: FBC, Kidney and liver function tests, C-reactive protein, lactate and blood cultures

Fluoroquinolones treatment

Stop Capecitabine and delay treatment for one week until recovery. Oxaliplatin at 100mg/m2 and Epirubicin at 75% dose

rendosy3 — 2020-06-24 11:19:23 UTC

rendosy3 — 2020-06-24 11:33:01 UTC

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3380874/

Raised in controlled manner at <12eq/L in 24hrs
With hypertonic saline until symptoms resolve or 135 blood serum achieved.
Then cyclizine

Likely causes: Kidney disease, Diabetes, Hypercalcaemia, Liver disease

2020-06-24 11:38:32 UTC

Blood tests: Electrolytes, calcium, Sodium, blood sugars, Pituitary function test

Monitor: Kidney function, Glucose, Liver

Treatment will depend on what the problem is

Tumour Lysis syndrome prophylaxis.

2020-06-24 12:00:04 UTC

In this case ,Yes the patient does require the above prophylaxis. This is because the diagnosis , this can be a life - threatening complication of the disease. TLS can develop rapidly & can be difficult to treat once established. Pre-treatment biochemical assessment and TLS screen includes:Urea, creatinine, Uric acid,
Phosphate, potassium , Albumin, correct Calcium, consider baseline G6 pD screen in a “at risk” patients.
Start of treatment: Allopurinol 300mg daily for whole course treatment.

Case Patient 1, part a questions

2020-06-24 13:31:09 UTC

part a) fever > 37.5 or generally unwell. Heart Rate >90, Respiratory Rate >20 Systolic BP *Patients will not always present with a fever and may not look unwell, however they can deteriorate rapidly and are at risk of death*

Confirmed with neutrophil count of < 1.0 x 109/L.