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Case history

image A 65-year-old man with a 4 year history of non-Hodgkin’s lymphoma and currently undergoing third-line chemotherapy for a second relapse of his disease presented with neutropenic sepsis, 12 days after his third cycle of chemotherapy. He had otherwise been well.

He was admitted and commenced on broad spectrum antibiotics. Over the next 96 h he deteriorated and developed acute respiratory failure. He now needs 85% oxygen by mask and his oxygen saturation level is 88%. His breathing is laboured.

What is the differential diagnosis?

What should the initial management be?

What are the benefits of critical care in this context?

What is the ethical context?

What is the differential diagnosis?

Sepsis alone does not wholly answer the issue in this case. There are five possibilities:

  • inadequately treated sepsis and progression of organ failure;

  • adequately treated sepsis following a predetermined cascade of organ failures;

  • a related problem, such as fluid overload in the context of acute pulmonary inflammation, resulting in pulmonary oedema;

  • drug-induced pneumonitis;

  • disease progression.

The clinical approach is to review all microbiological test results and ensure all microbiological causes have been covered. This will probably involve a change of medication and (re)sending further samples to the laboratory. In terms of fluid overload, ward fluid charts are often unhelpful. Reliance has to be on clinical signs. One of the risks is ‘hidden’ fluid and sodium loading due to fluids given as part of drug treatments. For example, high dose co-trimoxazole treatment for Pneumocystis infection will often entail infusion of 2000 ml normal saline per 24 h. Rather than just giving diuretics, the sodium loads need to be curtailed.

Disease progression is often a diagnosis of exclusion, as is pneumonitis, but it needs to be discussed, treated and investigated if reasonably possible.

The high-risk patient

Neutropenic sepsis is a medical emergency requiring a rapid response. Nevertheless, its management is no different from that of sepsis in any other context and the risks are broadly similar. While there has been a multitude of guidance on sepsis management, at its heart there are only a few interventions that make a difference to outcome. These are:

  • prompt, appropriate antimicrobial treatment;

  • removal of the focus if possible;

  • early recognition of an elevated risk of impending organ failure and transfer to a higher level of care where appropriate.

Sad to say after about $1 billion of randomized controlled drug trials and ‘magic bullet’ research over the past 20 years, nothing else has strong evidence of benefit. Sepsis treatment is beguilingly simple, just one step away from first aid, and yet so difficult to implement in a complex healthcare environment.

What should the initial management be?

The single most important element of initial management is simply to recognize that the patient is ...

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