Journal of Emergency Nursing
Volume 35, Issue 3 , Pages 184-185, May 2009

January Febrile Neutropenia Article

Clinical Coordinator/Flight Nurse, PennSTAR Flight, Division of Traumatology and Surgical Critical Care, University of Pennsylvania Health System, Philadelphia, PA

Article Outline

 

Dear Editor:

The clinical article by Cull and Nolan1 that discusses neutropenic fever, though well written, omits some very important points. The discussion that cites required laboratory studies for this population of patients does not mention the importance of measuring the serum lactate level. This measurement has taken on significant value in the initial evaluation and triage of all potentially septic patients regardless of suspected etiology. Several studies have shown the importance of measuring serum lactate level as a predictor of tissue hypoperfusion in patients who are not yet hypotensive. Shapiro et al2 showed an increased mortality rate in infected patients with lactate levels greater than 4 mmol/L while in the emergency department.

Rivers et al,3 in their groundbreaking study on early goal-directed therapy, coined the term cryptic shock to describe those patients who had an elevated serum lactate level but who were not yet hypotensive. They also showed an increased in-house mortality rate in this subset of patients. The measurement of serum lactate level enables ED staff caring for potentially septic patients to identify those patients who are at risk but who may not yet be showing significant hemodynamic instability earlier in their course of care.

The article further describes that an increasing heart rate (>100 beats/min) along with a “dropping” blood pressure may indicate sepsis. Sepsis is actually a continuum beginning with systemic inflammatory response syndrome, and there are 4 criteria for this syndrome (hypothermia/hyperthermia, tachycardia with a heart rate >90 beats/min, tachypnea with a respiratory rate >20 breaths/min or partial pressure of carbon dioxide [arterial] on arterial blood gas analysis <35 mm Hg, and white blood cell count <4 THO/uL or >12 THO/uL or an absolute band count >10%). When there are indications of inflammation and a documented or suspected infection is present, sepsis exists.

Sepsis is further defined as severe sepsis (sepsis with evidence of end-organ dysfunction) and septic shock (severe sepsis with hypotension that does not respond to intravenous fluids) boluses). The patient referenced in this article is exhibiting more than “sepsis”; she is actually in septic shock.

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References 

  1. Cull LF, Nolan MB. Treating neutropenic fever in the emergency department: delays may be deadly!. J Emerg Nurs. 2009;35:36–39
  2. Shapiro NI, Howell MD, Talmor D, Nathanson LA, Lisbon A, Wolfe RE, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med. 2005;45:524–528
  3. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. for Early Goal-Directed Therapy Collaborative Group Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–1377

 Submit all Letters to the Editor online at http://ees.elsevier.com/jen/

PII: S0099-1767(09)00125-1

doi:10.1016/j.jen.2009.03.004

Refers to article:

  • Treating Neutropenic Fever in the Emergency Department: Delays May Be Deadly! , 16 September 2008

    Lisa F. Cull, Mary Beth Nolan
    Journal of Emergency Nursing January 2009 (Vol. 35, Issue 1, Pages 36-39)

Journal of Emergency Nursing
Volume 35, Issue 3 , Pages 184-185, May 2009

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