Fever and Neutroprenia Guidelines

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File printed Nov4-08/as Fever +/- Neutropenia is a Medical Emergency Definition: o o Oral temperature 38.5 C (or 38 C x 2 readings taken 1 hour apart) ANC
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   BC Children’s Hospital Oncology/Hematology/BMT Dept Page 1 of 4Oncologic Emergencies - Fever & Neutropenia Guidelines Rev June 2006 Fever +/- Neutropenia is a Medical Emergency Definition :Oral temperature >38.5 o C (or >38 o C x 2 readings taken 1 hour apart)ANC <1 x 10 9  /L Triage :It is recommended that the BCCH Clinical Pathway be followed and the recommendations forempiric antibiotic use be implemented. (CAVEAT: Individual Hospital Infection Control Policymay dictate other treatment based on their own antibiotic sensitivity profile).The treating pediatric oncologist (after hours, the oncologist on call) should always be notifiedwhen a child on active anticancer therapy develops a fever and neutropenia.Please see the following pages for Practice Guidelines for Fever and Neutropenia patients . File printed Nov4-08/as  Clinical Practice Guideline for FEVER & NEUTROPENIA for patientsseen outside BCCH (On Active Therapy: Chemotherapy, Radiation Therapy, &/or Post HSCT) Physician-on-Callor Clinic receives callfrom parent:Child has Fever Information collected:   Name, Age, Phone numberDiagnosisSymptoms (rash)TemperatureTime of Last AcetaminophenStage of treatmentDate of last Chemo/RadiationDate of HSCTMost recent countOn GCSFCentral lineEstimated time of arrivalBring Patient Information Binder Yes Within 5 minutes: -Vital Signs (HR,RR,BP)-Temperature*-± 0 2 Sat-LOC-Isolate if possible No Treat asregular patientChild arrives inEmergency with history offever(38.0°Ax or 38.5°po) * No Rectal Temperatures *** Wash Hands ***Isolate patient in singleroom OnChemotherapy,Radiation, orPost-HSCT?ANC= sum of Neutrophils + bandsSignsof Septic Shock?LOC,BP,perfusion Triage as Level I: Assessed by ER PhysicianVS with BP q 5-15 min.If CVL, access all lumensDraw blood Stat:-C&S from all lumens-CBC & diff-Lytes, BUN, Cr, Glucose-Coag studies-Group & Screen-Venous Gas-CRPIf no CVL, start IV X2 &draw above bloodworkWeight YesNo Triage as Level II: Assessed by ER PhysicianVS with BP q 30 min.If CVL, access all lumensDraw blood Stat:-C&S from all lumens-CBC & diff-Lytes, BUN, Cr-Group & Screen-CRPIf no CVL, start IV & drawabove bloodwork.Weight If CVL blocked, see WithdrawalOcclusion Guidelines, but donot delay treatment. Startperipheral IV STAT Blood work resultsand clinical assessmentdetermine care Antibiotics as perEmpiric Antibioticdated June 2006ConsiderOutpatient IVCeftriaxone inpatients with lowrisk features onlyand clinicallystable. No IsANC < 0.3?Notify BC’sChildren’sHospitalOncologist -on-call604-875-2161Other cultures asclinically indicated-urine-stool-throat-NPW-CXrayRisk ofCommunicableInfection?VSStabilized? YesYesYesNoNo Admit to privateroomICUAdmit and IsolateAntibioticsas per High RiskFeatures (seeEmpiric AntibioticProtocol datedJune 2006IV -NS bolus over½ hr at 10ml/kgRepeat asnecessary.ConsiderDopamine Within 10 minutes: If renal impairment or oncisplatinum protocol,Ceftazadime alone (unlesshigh risk features requireadditional antibioticsArrange for return within 24 H Empiric Antibiotic Protocol forFever and Neutropeniapp 273-2752002/2003 Pediatric Drug DosageGuidelinesFourth Edition* Individual Hospital Infection ControlPolicy may dictate other Rx based ontheir own antibiotic sensitivity profiles File printed Nov4-08/as  Clinical Practice Guideline for FEVER & NEUTROPENIAfor BC Children’s Hospital patients (On Active Therapy: Chemotherapy, Radiation Therapy, &/or Post HSCT) Physician-on-Callor Clinic receives callfrom parent:Child has FeverName, Age, Phone numberDiagnosisSymptoms (rash)TemperatureTime of Last AcetaminophenStage of treatmentDate of last Chemo/RadiationDate of HSCTMost recent countOn GCSFCentral lineEstimated time of arrivalBring Patient Information Binder Yes Within 5 minutes: -Vital Signs (HR,RR,BP)-Temperature*-± 0 2 Sat-LOC-Isolate if possible No Treat asregular patientChild arrives inEmergency with history offever(38.0°Ax or 38.5°po) * No Rectal Temperatures *** Wash Hands ** OnChemotherapy,Radiation, orPost-HSCT?Signsof Septic Shock?LOC,BP,perfusion Triage as Level I: Assessed by ER PhysicianVS with BP q 5-15 min.If CVL, access all lumensDraw blood Stat:-C&S from all lumens-CBC & diff-Lytes, BUN, Cr, Glucose-Coag studies-Group & Screen-Venous Gas-CRPIf no CVL, start IV X2 &draw above bloodworkWeight YesNo Triage as Level II: Assessed by ER PhysicianVS with BP q 30 min.If CVL, access all lumensDraw blood Stat:-C&S from all lumens-CBC & diff-Lytes, BUN, Cr-Group & Screen-CRPIf no CVL, start IV & drawabove bloodwork.Weight If CVL blocked, see WithdrawalOcclusion Guidelines Results of the counts:-if WBC <0.5, pageoncologist-on-call-if WBC >0.5, wait forANC result, then pageoncologist-on-call.Antibiotics as perEmpiric AntibioticProtocol datedJune 2006ConsiderOutpatient IVCeftriaxone inpatients with lowrisk features only.Notify Oncologyservice No IsANC < 0.3?Page Oncologist -on-call604-875-2161Other cultures asclinically indicated-urine-stool-throat-NPW-CXrayRisk ofCommunicableInfection?VSStabilized? YesYesYesNoNo 3B or otherinpatient unitICUIsolateAntibioticsas per High RiskFeatures (seeEmpiric AntibioticProtocol datedJune 2006)IV -NS bolus over½ hr at 10ml/kgRepeat asnecessary.ConsiderDopamine Within 10 minutes: If renal impairment or oncisplatinum protocol,Ceftazadime alone (unlesshigh risk features requireadditional antibioticsArrange forreturn to OPDor Emergencydept within 24H Empiric Antibiotic Protocol forFever and Neutropeniapp 273-2752002/2003 Pediatric Drug DosageGuidelinesFourth Edition Oncology Clinic(will try toaccommodateif at allpossible)Emergency Rm(Oncologist willcall ER withpertinent info) Send specimens to lab viatube system if possibleANC = sum of Neutrophils + bands Notify CTU of admission File printed Nov4-08/as  Gram PositiveIf patient stable, wait forsensitivitiesIf patient deteriorating, addvancomycinLow-risk patients: admit Septic Shock or Admissionto ICU Vancomycin+ meropenem+ gentamicin EMPIRIC ANTIBIOTIC PROTOCOL FOR FEVER AND NEUTROPENIA FEBRILE NEUTROPENIC PATIENT ANC <1 10 9  /LOral temperature >38.5°C (or >38°C 2 readings 1 hour apart) AMPHOTERICIN B1 mg/kg/dose+Benadryl 1 mg/kg/dose+hydrocortisone 1 mgper 1 mg amphotericin(max 25 mg/dose)CEFTRIAXONE100 mg/kg IV dailyMax 2 g/24 hVANCOMYCIN40-60 mg/kg/day q8hMax 1 g/doseBaseline creatinine then twiceweekly. Trough level 30 minutesbefore 3 rd -5 th dosePIPERACILLIN / TAZOBACTAM300 mg/kg/day ofpiperacillin q6hMax 3 g/dose of piperacillinGENTAMICIN“Once daily dose” -recommended at BCCH7 mg/kg/day given once daily over 30 minutesCreatinine at baseline and twice weeklyTrough level 18-24 hours after second dosethen weeklyIf level < 1 mg/L, continue same dosingIf level > 1mg/L consult pharmacyDOSESCeftriaxone in OPD or ER 3 days.Re-evaluate daily. Revised June 13, 2006  Culture NegativeAfebrileDiscontinue antibiotics after48 hours if ANC >0.30 andrising.Still FebrileRe-evaluate patientAdd amphotericin B after 4-6 daysGram NegativeLow-risk patients: admit(concurrent gentamicinrecommended) Rationalize antibiotics based on sensitivities and maintain broad-spectrum coverage. Culture PositiveBlood Culture These are only guidelines and full clinical evaluation is required for all febrile patients. INTERMEDIATE / HIGH RISK Admit LOW RISK Treat in OPD (only for patients seen at BC Children’s Hospital or in consultation with a pediatric oncologist at BC Children's) Features:ANC >0.3 10 9  /LPlatelets >20 10 9  /LClinically well with viral symptomsCRP <10 (if available)Reliable parents and easy accessto return to hospital Piperacillin/tazobactam+ gentamicin Renal impairment* or cisplatin treatment Piperacillin/tazobactam+/-gentamicin **HIGH RISK FEATURES Post BMTCurrently on a relapse protocolAML on therapyDown syndromePrevious sepsis in last 4 weeksMucositisSuspected typhlitisNo high risk features***Renal impairment = twice patient’s baselinecreatinine or GFR < 90 ml/min/1.73 m 2 MEROPENEM60 mg/kg/24 hoursIV q8hGENTAMICIN“Divided dose”7.5 mg/kg/day q8hLevels pre/post 3 rd dosethen pre-level onlyonce/week Either / Or File printed Nov4-08/as
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