Neutropenic sepsis
Neutropenia is defined as a neutrophil count of <0.5 × 109/L, which is a common treatment-related toxicity. When associated with a fever of >38°C it is known as febrile neutropenia. Infection can rapidly progress to fatality, so prompt recognition and treatment is paramount. There should be a high index of suspicion in all patients who have recently received chemotherapy, and although there are other causes of fever in the cancer patient, infection should always be assumed until proven otherwise. Neutropenia can occur following radiotherapy if large volumes of bone marrow are irradiated, or may be part of pancytopenia due to malignant infiltration of the marrow.
Initial management should include an infection screen comprising: blood cultures (peripheral and from central line if present), MSU, chest X-ray and swabs for culture (e.g. throat, central line site). No additional microbiological assessments are of benefit in the absence of localising signs of infection.
The standard approach is then to commence empirical antibiotics according to local hospital policies agreed with the microbiologists and based on the local antibiotic resistance patterns observed. First-line empirical therapy is either monotherapy with tazocin or meropenem, or with the addition of gentamicin. Metronidazole may be added if anaerobic infection is suspected, and flucloxicillin, vancomycin or teicoplanin if Gram-positive infection is suspected. Antibiotics should be adjusted according to culture results, although these are often negative. If there is no response after 36–48 hours, antibiotics should be reviewed with microbiological advice and antifungal cover should be considered. G-CSF is not routinely used for all patients with neutropenia and guidelines for use have been established.
Superior vena cava obstruction
Obstruction of the superior vena cava (SVC) by mediastinal tumours occurs most frequently with lung cancers, especially SCLC, but also with lymphoma, germ cell tumours and metastasis from other tumours. It may also be caused by a thrombus, especially in patients with a central intravenous catheter.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
