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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Hematology & Oncology : Fever & Neutropenia

These are general guidelines for management of patients with hematologic and oncologic diseases and disorders. Please discuss management questions and arrange admission or discharge planning with the hematology/oncology fellow on call.

Risk of serious infection increased when ANC < 500/ mm3

  • Bacteremia risk increases w/ ANC < 100/mm3
  • Fever = 101
  • Neutropenia often occurs 7-10d after chemo

Most oncology patients have indwelling central lines so immediate access is available. If the clinical appearance and the vital signs of the patient are stable, please consider using EMLA or ELAMAX on their port-a-cath if they desire that to ease the pain of access. If they are ill-appearing, access will need to be obtained immediately to best manage the patient's illness. Often times, these patients are well-known to our child life staff so please allow them to be involved in reducing the patient's pain and anxiety.

Labs ASAP:

  • CBC with diff and plt
  • Blood cx from each lumen of CVL, +/- peripheral
  • BMP often with Ca, Mg and Phos depending on what chemo they received most recently
  • Hold type and screen
  • Coags (w/ fibrinogen and D-dimer) if ill-appearing

START antibiotics as soon as cultures are obtained.

Special Considerations:

  • No suppositories or rectal temperatures
  • No IM injections
  • If you believe you need a urine cx and patient is in diapers, use a bag...NO CATH unless cleared by Heme/Onc attending

Empiric antibiotic for FONs:

  • Cefepime 50mg/ kg/dose q8h (max 2gm)
  • Hypotensive with chills:
    • Cefepime and Gent (2.5mg/kg) and bolus IVF
    • Main concern is for gram negative infections/sepsis that can progress rapidly
  • Abdominal pain:
    • Cefepime, Gent and Flagyl (7.5mg/kg)
    • Consider imaging with CT or kub to r/o typhlitis
    • Consider stool cx for C. diff
  • Presumed CVL and tunnel infections:
    • Cefepime and Vancomycin (20mg/kg)


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