Neutropenia

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Rebecca Donohue, who will be talking with us about any and all questions you have regarding Neutropenia. Welcome Rebecca!

 Rebecca Donohue 

Hello. Where is everyone from?

 oncnurse 

Massachusetts

 maryston 

Fort Worth Texas

 Lisa B. 

Philadelphia

 Rebecca Donohue 

I'm in Louisiana. Are there any burning questions?

 oncnurse 

I'd like to know if people are doing risk assessments of pts for neutropenia.

 Rebecca Donohue 

Good question. We do have a risk assessment that is done prior to 1st chemo course.

 Lisa B. 

I am not working specifically w/ chemo in my current position. What do you mean by risk assessment?

 Rebecca Donohue 

There are risk factors that have been identified that place pt at increased risk for neutropenic complications.

 Rebecca Donohue 

NCCN has these on the site.

 Rebecca Donohue 

They can be patient related or chemo-related.

 Rebecca Donohue 

We looked at the risk factors and along with the docs I work with decided which factors we wanted included in a risk assessment tool to use before treatment.

 Lisa B. 

Are you referring to NCCN guideline on preventing ca-related infections?

 Rebecca Donohue 

Chemotherapy induced neutropenia infections or febrile neutropenia

 Rebecca Donohue 

NCCN recommends proactive use of G-CSFs for pt with risk factors.

 Rebecca Donohue 

These risk factors include chemo regimens >20% risk of febrile neutropenia (FN)

 dafurtick@aol.com 

Due to the use of chemo...won't most patients become neutropenic? Or is it related to the type of chemo? For instance oral verses IV?

 Rebecca Donohue 

The type of chemo determines risk. NCCN has a list of chemo regimens that are >20% that they recommend prophylactic use of G-CSF.

 Rebecca Donohue 

This can be oral or IV.

 Lisa B. 

I am on NCCN site. It looks like the one titled Myeloid growth factors is the one you referred to…

 Rebecca Donohue 

Myeloid growth factors are for anemia

 Rebecca Donohue 

granulocyte stimulating factors are for prevention of infection.

 Rebecca Donohue 

Granulocyte colony stimulating factors (G-CSF)

 Lisa B. 

Anemia is covered under chemo-induced anemia guideline. Unfortunately the guideline discussing neutropenia is called myeloid GF.

 Rebecca Donohue 

Typically called G-CSF

 Rebecca Donohue 

Other risk factors include comorbid conditions, age > 65y, previous experience with FN.

 maryston 

I currently have a patient with relapsed AML, she came in (inpatient) on 3/30 with fever and an ANC of 0.00.

 Rebecca Donohue 

This pt would need supportive care with IV antibiotics, possibly antifungals.

 Rebecca Donohue 

What was done?

 Rebecca Donohue 

Was this expected from chemo?

 maryston 

She's been on antibiotics, antifungals and antivirals. She also received novantrone and etoposide for 5 days in an effort to get the leukemia into remission.

 Rebecca Donohue 

This is a pt that would have been taught when to call the MD -- important part of neutropenic teaching.

 Rebecca Donohue 

Basically when neutropenia is an expected effect of the chemo pt would be instructed to take their temp 3-4 times a day and as needed.

 Rebecca Donohue 

Also, to call with any signs of infection: cough, dysuria, diarrhea, etc

 maryston 

Also not to ignore chills at any time.

 Rebecca Donohue 

Absolutely, remember when there is no wbc's fever may not occur.

 Rebecca Donohue 

So we look for other signs of infection, confusion in the elderly is commonly the only sign.

 maryston 

I see a lot of UTI's.

 Rebecca Donohue 

Yes UTI's are a common source of infection.

 Rebecca Donohue 

Do any of you use prophylactic antibiotics?

 Rebecca Donohue 

What neutropenic precautions do you instruct?

 oncnurse 

Teach meticulous hand hygiene first!

 oncnurse 

No direct care for pet’s litter box, etc. avoid people with colds or who say that they are feeling sick.

 oncnurse 

Protect skin, bathe daily, dry thoroughly.

 oncnurse 

Gloves in the garden

 Rebecca Donohue 

Yes, also hand hygiene for all visitors.

 dafurtick@aol.com 

I am fairly new at this, what do you mean by "when there is no wbc's fever may not occur"? It should make sense to me; since you need your wbc's to fight off infection....so how do we know they are sick?

 Rebecca Donohue 

Elevation of the white blood cells is the natural defense for infection

 Tricia 

Why no direct care for pets?

 Rebecca Donohue 

When there are no wbc's there is no way for them to elevate. This elevation is when you see fever.

 maryston 

Avoid crowds, movies, the mall etc

 Lisa B. 

I hear w/ transplants, some fruits are being allowed in the diet. What fruits? Thick-skinned/peelable?

 Rebecca Donohue 

It is actually no direct care of the feces, saliva, urine, etc. of animals.

 Tricia 

We always tell our patients no flowers and no fresh fruits/vegetables unless they can be peeled.

 oncnurse 

Yes, it means no contact with urine, feces, saliva, litter box of pets...careful of scratches.

 Tricia 

Thank you Rebecca, that makes more sense.

 Rebecca Donohue 

This is sources of bacteria.

 oncnurse 

Also farm animals! In case you live in a rural environment!

 jdmazrn 

In direct inpt care, my facility directs us to wear a mask "if you have or feel like you are getting a cold" and to direct the pt to wear a mask when leaving the room. Is this sufficient?

 maryston 

Evidence doesn't support avoiding fresh fruits and vegetables.

 Rebecca Donohue 

Correct no fresh flowers or plants because of the stagnate water risk with molds.

 Rebecca Donohue 

Risk from fresh fruits/veggies is controversial.

 Rebecca Donohue 

Research is needed to show if avoidance of fresh fruits/veggies is needed.

 Tricia 

Yes but the doctors still instruct the pt's on no fresh fruits/veggies.

 maryston 

Our ID docs do, but not the ONC docs.

 Rebecca Donohue 

Guidelines support use of masks with transit.

 Rebecca Donohue 

Good hand washing of anyone entering the pt room before touching anything is also recommended.

 Rebecca Donohue 

Avoiding raw meats and seafood is common sense.

 Tricia 

When caring for inpatient neutropenic patients is it necessary for all entering the patient's room to wear a mask?

 Tricia 

Is all seafood to be avoided or just shellfish?

 Rebecca Donohue 

Avoidance of fresh fruits/veggies is at the discretion of the practitioner.

 Rebecca Donohue 

All raw seafood should be avoided.

 Rebecca Donohue 

I don't know of the recommendation for all entering the room to wear masks.

 Rebecca Donohue 

Use of a mask & gown when entering room is recommended for MRSA pts.

 Rebecca Donohue 

Also need to avoid reptiles & birds -- due to weird contamination that is possible.

 Rebecca Donohue 

Avoid live fish also…

 Lisa B. 

Yes, fruits and vegetables are not evidence-based. But CDC safe food handling is recommended.

 Rebecca Donohue 

Reptiles many may think unnecessary to warn against but remember people have pet snakes and lizards.

 Rebecca Donohue 

Any federal recalls on foods (pistachios, spinach, etc) need to be strictly adhered to be neutropenic pts.

 oncnurse 

What are your recommendations for prevention of mucositis?

 Rebecca Donohue 

Mucositis is a risk for infection in neutropenia.

 Rebecca Donohue 

For treatment oral saline/salt rinses are best -- Warm salt water like Mom always taught!

 Rebecca Donohue 

Prevention for mucositis includes avoiding alcohol mouthwashes, no smoking, soft toothbrush use…

 Rebecca Donohue 

Basically gentle mouthcare…

 Rebecca Donohue 

Cryotherapy (ice chips) may help prevent mucositis with some chemos (5FU).

 Rebecca Donohue 

Does anyone use cryotherapy?

 oncnurse 

No

 Rebecca Donohue 

If a person is a smoker, we pay special attention to their mouth care and anticipate possible mucositis?

 Rebecca Donohue 

Pts are instructed to call us with the occurrence of any mouth sores or white patches in the mouth?

 Rebecca Donohue 

We do use "magic mouthwash" but the Benadryl in it is actually shown to cause drying of the mucous membranes and may increase mucositis.

 maryston 

Ever use GelClair?

 Rebecca Donohue 

Yes, pt find it helpful as long as they are not wanting to eat or drink - this dissolves it.

 Rebecca Donohue 

Regular teeth brushing with soft brush is good, but I tell pt not to overdo it -- 2 or 3 times a day is plenty.

 Rebecca Donohue 

Also to avoid acidic and highly seasoned foods like orange juice and tomato bases, and particularly around here the Cajun food.

 Rebecca Donohue 

Any tips you give?

 Lisa B. 

Check out the PEP cards on prevention of infection and mucositis.

 dafurtick@aol.com 

PEP cards? Where do you find these?

 Laurl at ONS 

Yes, the ONS PEP card is very complete, evidence-based (gives interventions based on level of evidence- from high to ineffective) and easy to use.

 Laurl at ONS 

You can get the cards from ONS directly or download off of the website. Search for PEP

 dafurtick@aol.com 

Thank you

 Lisa B. 

Go to ONS website and go to research/PEP area. They are pocket cards with evidence based recommendations.

 Laurl at ONS 

There are a lot of them: many symptoms researched well.

 Rebecca Donohue 

PEP -- Putting Evidence into Practice

 Rebecca Donohue 

These cards are a quick go to place to find out what does and does not work.

 Rebecca Donohue 

Any other burning issues?

 Laurl at ONS 

It's about five minutes before our time is up - as you continue to ask questions, please don't forget to take a moment to cut and paste this URL into your browser and take our very brief survey at the end of the chat-we'd love to hear what you think of these chats! The URL is http://research.zarca.com/k/RsTUTRsSUWsXYTXRsPsP

 Laurl at ONS 

We'd also love your ideas on future chat topics- if you have some, let us know!

 Rebecca Donohue 

Neutropenia is an expected adverse effect of many chemo regimens. Awareness of this risk, prophylaxis where appropriate and good patient teaching on when to call the MD or go the ER can help pt to go through their treatment with greater ease.

 Rebecca Donohue 

Patient advocacy is what nurses do best. Thanks everyone.

 Laurl at ONS 

Thank you all for attending! Please check out the ONS website for future chat topics and dates!

 Laurl at ONS 

Thanks Rebecca!

 Rebecca Donohue 

Goodbye!