Page 655 - ONLINE PROCEEDING BOOK WSAVA 2017
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prior treatment.
In my experience, there is less than a 5% chance that a patient will need hospitalization. If this does occur, these patients are usually hospitalized for typically 24-48 hours with supportive care including IV  uids and antibiotics.
In my experience most chemotherapy patients can successfully receive that drug again with a dose reduction.
What to do at the nadir visit?
In addition to running a CBC, it is important to
get a good history, TPR (fever is so important in neutropenic patients), and a complete physical examination. I am always interested in knowing how the patient handled chemotherapy –did she eat well, any vomiting/diarrhea, did the owner
use any nausea or diarrheal medications? For the exam, did he lose weight, was she febrile? The nadir CBC should not be a technician appointment to just pull the blood sample. The history and exam are very important.
Pay attention to the neutrophil count, not the total white blood cell count. The nadir typically occurs 7 days after chemotherapyadministration, but can vary (see above). I recommend antibiotics if the neutrophil count is <1500. If the patient has <1500 neutrophils and is afebrile and feeling well, I recommend managing as an outpatient. However, if the patient has <1500 neutrophils and is febrile and sick, I recommend admitting for supportive care. Remember a febrile neutropenic is an oncologic emergency.
Also, I prefer that we get blood samples from the jugular veins for patients getting IV chemotherapy (unless thrombocytopenic). Save those peripheral veins for treatment please. Finally many times the oncologist
has run a recent chemistry panel, so check with the oncologist, and try not to repeat unneeded blood work to keep costs down.
Sepsis
Sepsis in chemotherapy patients is typically due to patient’s own  ora - Gram negative from GI bacteria: E. coli, Klebsiella, Pseudomona; Gram positive from skin bacteria: Staphylococcus epidermitidis and aureus, Anaerobes from oral bacteria. Predisposing factors include neutropenia (infection risk well correlated with
An Urban Experience
degree and duration), cellular immune dysfunction, humoral immune dysfunction, prolonged hospitalizations, indwelling catheters, and poor nutrition.
History and clinical signs are typically straightforward
- cytotoxic chemotherapy was administered typically
5 to 7 days ago. Remember, the febrile neutropenic patient is an oncologic emergency!!! In addition the patient may have an inability to mount an in ammatory response, so the lack of fever, pyuria, or radiographic changes of pneumonia does not rule out sepsis. Signs of illness are unrelated to absolute neutrophil count, but are related to an increased susceptibility to local and systemic infections when neutropenic. Gastrointestinal, urogenital, and respiratory infections are most common. Shock is also possible
The sepsis work up includes: CBC, Chemistry panel, UA & UCS (if >50,000 platelets). If respiratory signs are present, chest radiographs are recommended, and TTW should be considered. Blood cultures may be needed, but uncommon in my experience. Culture any catheters suspected as the infection source.
Treatment for sepsis includes: IVF and broad-spectrum IV antibiotics. Neupogen is human recombinant G-CSF. The MOA is stimulation of proliferation & maturation
of neutrophil precursors, and monocyte precursors
to a lesser extent. It also primes neutrophil for cell killing & neutrophil migration. The bene t for the febrile & febrile neutropenic patient is contradictory, and
in my experience, Neupogen is rarely needed. The recommended dose is 5 ug/kg SQ SID until neutrophil >1000.
When should I lower chemotherapy dose?
Dose Intensity is chemotherapy given at MTD
& shortest possible interval. It is important to remember than small dose changes can have signi cant impact on cancer control. Dose reductions as small as 20% can decrease drug ef cacy up to 50%. Dose reductions should not be considered lightly.
CHEMOTHERAPY SAFETY
Chemotherapy requires careful prescription preparation, drug dispensing, drug administration, client education, and safe handing of patients by ALL staff. Chemotherapy exposure has been documented in nurses and pharmacy workers. It is important to protect your team, our clients, & follow protocols.
To protect your staff, the following are recommended a hood, closed system transfer device, dedicated counting equipment, dedicated chemo fridge, and Personal protective equipment (PPE) including gloves, gowns, chemo mat, and eye protection. Closed system transfer device such as PhaSeal® are leak-proof and airtight
Neutrophil count (per uL)
Fever,
Systemic Signs
Plan
1500-2500
No
Monitor +/- treatment delay 2 to 4 days
<1500
No
Oral antibiotics treatment delay Consider dose change
<1500
Yes
ATH for IVF & IV antibiotics treatment delay Dose reduction
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