Download Raising Awareness of Neutropenic Sepsis

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 pathophysiology around NS
• To articulate how a patient with NS should
be managed initially
Treatment of cancer
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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
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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
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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
Presence of viable bacteria in
the blood
Bacteraemia
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
Sepsis with one or more signs
of organ dysfunction
Severe Sepsis
Septic Shock
Bone et al 1992
Sepsis with hypotension
unresponsive to fluids
Breakdown of
skin/mucous
membrane
Risk factors
Neutropenia
Antibiotic use
Invasive procedures
Increased risk of
septic shock
Age >65
or<1 yr
Corticosteroids and
immunosuppressive
therapy
Malignancy
Hospitalisation
Malnutrition
Radiotherapy
Splenectomy
Chemotherapy
SOURCE OF INFECTION
Release of endo/exo
toxins
IMMUNE RESPONSE
Recruitment of
plasma cells;
neutrophils,
macrophages,
monocytes
Release of cytokines,
proand antiinflammatory 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 hypoperfusion,
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 hospital
delay in diagnosis
delay to first dose of antibiotic
neutropenic 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
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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
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H- History
E- Examine
A- Action
T- Treat
Take home message
Patient on chemotherapy?
Be suspicious
ACT FAST TO PREVENT DEATH