Neutropaenic Fever Hot Case

GENERAL APPROACH

Infectious

• community acquired
• nosocomial (surgical site, lines, chest, urine, sinusitis)

Non-infectious

• head injury
•  DVT -> PE
• drug/toxin
• SIRS (post surgery, trauma, aspiration, pancreatitis)
• Hypermetabolic syndromes

-> thyroid storm
-> NMS
-> MH
-> heat stroke
-> phaeo
-> liver failure
-> burns
-> cocaine toxicity
-> serotonin syndrome

Occult Fever

• ophthalmitis
• indwelling line sepsis
• colitis
• graft vs host disease

INTRODUCTION

CUBICLE

• isolation (MDRO)
• long stay patient (new problem -> nosocomial infection)

INFUSIONS

• antibiotics (MDRO)
• noradrenaline (sepsis)
• heparin (DVT -> PE)
• blood products (febrile reactions)

VENTILATOR

• level of support
• level of oxygenation (FiO2, PEEP)
• disease specific questions (ARDS: plateau pressure, bronchospasm: dynamic hyperinflation, intrinsic PEEP)

MONITOR

• temperature
• tachycardia (SIRS)
• ETCO2 (hypermetabolic syndrome)
• CVP (number, waveform)
• arterial trace (pressure, swing, pulsus paradoxus)

EQUIPMENT

• intra-abdominal drains (fluid, amount)
• EVD (recent cell count and culture)
• rectal tube (diarrhoea)
• active cooling (severe hyperthermia)
• epidural (inspect site and examine neurology)
• intercostals drains (number, bubbling, drainage)
• urine (colour, output, myoglobin, microscopy)

QUESTION SPECIFIC EXAMINATION

• hands/arms -> head -> chest -> abdo -> legs/feet -> back

-> cardiovascular
-> respiratory
-> abdominal
-> haematological

• neurological

-> paralysed
-> quick examination
-> unconscious
-> conscious

• vaginal examination for retained tampon
• age of lines
• recent anaesthetics (MH)
• recent antibiotic exposure (drug fever)

RELEVANT INVESTIGATIONS

• CXR
• FBC: WCC
• microbiology: sputum, blood cultures, urine, line cultures, intra-abdominal samples
• burn biopsy

OPENING STATEMENT

• My approach to fever in this patient is to look at Infectious and Non-infectious causes
• I believe that this patient has multiple possible causes for fever:
• List headings of causes -> clinical signs associated with list