Fever - Oncology patient

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide emergency staff in the assessment and management of oncology patients who present with fever.

Risk

Oncology patients undergoing chemotherapy are immunosuppressed and at risk of sepsis. Early recognition and treatment is essential in these patients.

Key points 

  • The on call Oncology Fellow / Oncologist and Emergency Consultant must be notified immediately of ALL febrile oncology patients who are systemically compromised.
  • DO NOT ACCESS INFUSAPORT IF INSERTED WITHIN LAST 5 DAYS (unless under instruction of Oncologist)
  • The Oncology ward will provide a Patient Summary Sheet for expected patients who will be presenting to the Emergency Department. This will be given to the ED nurse co-ordinator and summarises patient diagnosis, allergies, alerts, treatment regimen, CVAD details and recent weight.  

Initial Management of Fever in Oncology Patient - PCH ED pathway

Definition

FEVER: Temp > 38.5°C or > 38.0°C on two sequential occasions in a 12 hour period

ALL CHILDREN PRESENTING TO THE EMERGENCY DEPARTMENT WITH FEVER OR UNWELL SHOULD BE TRIAGED AS ATS 2 (HIGH RISK) and on call oncology fellow or oncologist advised.

Note: Babies on chemotherapy, patients on high dose steroids, or with hypothalamic dysfunction may not mount a temperature.           

Clinical assessment

  • Full EDOES
  • Rapid comprehensive nursing and medical assessments.

Immediate IV Access

  • Do NOT wait for EMLA to act to access central venous device or insert peripheral line
  • Take Blood Cultures (aerobic & anaerobic), CRP, FBC, EUC, VBG – lactate
  • Administer IV antibiotics as soon as IV access obtained.

Other Investigations (if required)

  • +/- CXR
  • +/- Urine M/C/S
  • +/- CVL exit site swabs
  • +/- Resp virus PCR
  • +/- Stool M/C/S, viruses
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Do NOT wait for blood results before initiating treatment especially in patients known or expected to be neutropaenic* or in patient with a central line.

(*NEUTROPENIA: Absolute Neutrophil Count (ANC) < 500x106/L (i.e. 0.5x109/L) OR 500 –1000 and likely to fall further in next 48h)

Antibiotics MUST be commenced within 30-60 minutes of presentation and before undertaking other investigations ie CXR or NPA

Contact the on-call Oncology Fellow 

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 No evidence of systemic compromise

Systemically Compromised - Manage in resuscitation room

  1. Haemodynamic compromise 
  2. Respiratory compromise 
  3. Confusion or decreased consciousness
  4. End organ dysfunction – renal or hepatic dysfunction, coagulopathy
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 **Cefepime 50mg/kg (to a maximum of 2g)

Should be prescribed by Doctor as soon as patient weight is known.

For patients at high risk of infection add IV vancomycin.

RESUSCITATION fluids etc as indicated.
ANTIBIOTICS – in order:
  • **Cefepime 50mg/kg (max 2g)
  • Vancomycin 15mg/kg (max 750mg)
  • +/- Gentamicin: 7.5mg/kg (max dose 320mg) >1 month to 10 years, 6-7 mg/kg/dose (max 560mg) >10 year - 18 years old
  • Drug doses: Presumed bacteremia/sepsis - ChAMP guideline
  • **Some patients require antibiotics instead of Cefepime - refer to notes and Oncology Fellow on-call (source antibiotics from 1A if not available in ED prior to patient arrival)  
  • Beware of haemodynamic compromise following administration of antibiotics
  • Repeat EDOES and clinical assessment frequently for an hour AFTER 1st dose antibiotics
  • Discuss ALL patients with oncology fellow or paediatric oncologist via switchboard.


Endorsed by:  Director, Emergency Department   Date:  Feb 2018


 Review date:   Feb 2021


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