Department of Emergency Medicine, Hôpital Cochin, APHP, rue du Faubourg Saint-Jacques, Paris Cedex 14, France.
Crit Care. 2010;14(2):R68. doi: 10.1186/cc8972. Epub 2010 Apr 19.
Febrile neutropenia (FN) is common in cancer patients receiving myelotoxic therapy. The procedures to treat FN are well established in oncology, but it is unclear whether management is adequate in the emergency department (ED).
This prospective, multicentre, observational study was carried out in 47 French EDs for 6 months. Patients were adults presenting at the ED with FN after myelotoxic treatment for cancer. Severity of infection was defined according to Bone criteria for severe sepsis and septic shock (SS/SSh) and risk was determined according to Multinational Association of Supportive Care in Cancer (MASCC) criteria. The end point was the implementation of guidelines. Management of patients with SS/SSh required: (i) adequate intravenous (IV) antimicrobial therapy for the first 90 min (broad-spectrum beta-lactam with or without an aminoglycoside); (ii) fluid challenge (500 mL); (iii) lactate measurement; (iv) at least one blood culture; and (v) hospitalization. Management of patients without SS/SSh required: (1) no initiation of granulocyte - cell stimulating factor (G-CSF); (2) adequate IV antimicrobial therapy (broad-spectrum beta-lactam) and hospitalization if the patient was high-risk according to MASCC criteria; (3) adequate oral antimicrobial therapy (quinolone or amoxicillin/clavulanate or cephalosporin) and hospital discharge if the patient was low-risk.
198 patients were enrolled; 89 patients had SS/SSh, of whom 19 received adequate antimicrobial therapy within 90 min and 42 received appropriate fluid challenge. Blood cultures were obtained from 87 and lactate concentration was measured in 29. Overall, only 6 (7%) patients with SS/SSh received adequate management. Among 108 patients without SS/SSh, 38 (35%) were high-risk and 70 (65%) low-risk. In the high-risk group, adequate antimicrobial therapy was given to 31 patients, G-CSF was initiated in 4 and 35 were hospitalized. In the low-risk group, 4 patients received adequate oral antimicrobial therapy, IV antimicrobial therapy was prescribed in 59, G-CSF was initiated in 12 and six patients were discharged. Adequate management was given to 26/38 (68%) high-risk and 1/70 low-risk patients. Factors associated with adequate management were absence of SS/SSh (P = 0.0009) and high-risk according to MASCC criteria (P < 0.0001).
In this French sample of cancer patients presenting to the ED with FN, management was often inadequate and severity was under-evaluated in the critically ill.
发热性中性粒细胞减少症（FN）在接受骨髓抑制治疗的癌症患者中很常见。在肿瘤学中，FN 的治疗方案已经成熟，但在急诊科（ED）中，其管理是否充分尚不清楚。
本研究为前瞻性、多中心、观察性研究，在法国 47 家 ED 进行，为期 6 个月。FN 患者为癌症患者在接受骨髓抑制治疗后，因 FN 而在 ED 就诊。感染的严重程度根据 Bone 标准定义为严重脓毒症和脓毒性休克（SS/SSh），风险根据 Multinational Association of Supportive Care in Cancer（MASCC）标准确定。终点是实施指南。SS/SSh 患者的管理需要：（i）在最初 90 分钟内给予适当的静脉（IV）抗菌治疗（广谱β-内酰胺联合或不联合氨基糖苷类药物）；（ii）液体冲击（500 mL）；（iii）测量乳酸；（iv）至少进行一次血培养；（v）住院治疗。无 SS/SSh 患者的管理需要：（1）不启动粒细胞集落刺激因子（G-CSF）；（2）根据 MASCC 标准，高危患者给予适当的 IV 抗菌治疗（广谱β-内酰胺）和住院治疗；（3）低危患者给予适当的口服抗菌治疗（喹诺酮类或阿莫西林/克拉维酸或头孢菌素）和出院治疗。
共纳入 198 例患者；89 例患者有 SS/SSh，其中 19 例在 90 分钟内接受了适当的抗菌治疗，42 例接受了适当的液体冲击。87 例患者获得了血培养，29 例患者测量了乳酸浓度。总体而言，仅 6 例（7%）SS/SSh 患者得到了适当的管理。在 108 例无 SS/SSh 的患者中，38 例（35%）为高危，70 例（65%）为低危。高危组中，31 例给予适当的抗菌治疗，4 例开始使用 G-CSF，35 例住院治疗。在低危组中，4 例患者接受了适当的口服抗菌治疗，59 例患者给予了 IV 抗菌治疗，12 例开始使用 G-CSF，6 例出院。高危患者中 26/38（68%）和低危患者中 1/70 得到了适当的管理。适当管理的相关因素包括无 SS/SSh（P=0.0009）和符合 MASCC 标准的高危（P<0.0001）。
在本项法国 FN 癌症患者 ED 样本中，管理往往不充分，且重症患者的严重程度评估不足。
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