Has this ever happened to you?
A patient arrives for supportive care. On examination, they describe flu-like symptoms, and general malaise. Their blood pressure is low, but since their prescribed treatment is IV fluids for dehydration, you are not surprised. Perhaps they have a fever, but just as likely, they do not. You note that they received chemotherapy earlier in the week. What is your assessment? Do you consider febrile neutropenia?
I remember taking a patient with febrile neutropenia to the emergency department. Besides malaise, one extremity was red, swollen, and hot to touch. The patient's blood pressure was low, but still within normal limits, and the temperature was normal for age. I had a difficult time convincing the triage nurse that this patient was experiencing an oncological emergency. Fortunately, the emergency room doctor recognized febrile neutropenia, and the patient received appropriate treatment.
The presentation of febrile neutropenia is often insidious, particularly in the outpatient setting during supportive treatment. However, according to the British Journal of Cancer, not only can it quickly escalate into a medical emergency, but can also lead to a reduction of chemotherapy dosage, resulting in decreased survival rates, particularly for breast cancer patients.
Symptoms of febrile neutropenia can be subtle. Often, the only symptom is a fever in a patient at risk, but in severe cases, the patient may be unable to mount a febrile response. A fever is defined as a single temperature of 38.0°C (100.5°F) or a sustained temperature of 38.0°C for over an hour.
So, when should a nurse suspect that an oncology patient has febrile neutropenia?
Common signs and symptoms of infection are:
- Fever (if over 38.0°C (100.5°F)
- Red, swollen areas of skin, especially on the legs and arms
- Chills or rigor
- Cough or shortness of breath
- Sore throat or sores in mouth
- Loose or liquid stools
- Increased urinary frequency, burning sensation, or bloody urine
- Unusual vaginal drainage or itching
- Flu-like symptoms, such as head and/or body aches, and general fatigue
Any of the above symptoms presenting in an oncology patient require immediate notification of the oncologist or oncology nurse practitioner for laboratory tests, and prophylactic, broad spectrum antibiotics, or antifungals. Hospital admission should be considered based on the patient's presentation, and risk factors.
Patients and their caregivers must be instructed to call their oncology office immediately, day or night, if these symptoms occur at home.
What barriers have you experienced in recognition or treatment of febrile neutropenia?