Unfolding case: day eight of induction

Leukemia and lymphoma, in one panel

Acute leukemias fill the marrow with blasts, so the patient arrives anemic, thrombocytopenic, and neutropenic all at once. Acute myeloid leukemia is the common acute adult form; acute lymphoblastic leukemia is the common childhood form. Chronic lymphocytic leukemia is often found incidentally in an older adult; chronic myeloid leukemia carries the Philadelphia chromosome and can transform into blast crisis. Hodgkin lymphoma shows Reed-Sternberg cells and typically begins as a painless cervical or supraclavicular node spreading to adjacent node groups. Non-Hodgkin lymphoma is more varied, spreads without that orderly pattern, and is often widespread at diagnosis. Fever, drenching night sweats, and unintended weight loss are the systemic symptoms that push either one up the priority list.

The case

0800. A 38-year-old on day eight of induction chemotherapy for acute myeloid leukemia says she feels "a little off." Temperature 38.6 °C. Heart rate 112. Blood pressure 96/54, against a usual 118/70. Respirations 22. Oxygen saturation 96 percent on room air. This morning's absolute neutrophil count is 180/mm³.

0830. No localizing signs. The central line site is clean, without redness, drainage, or tenderness. Lungs clear. Mild right flank ache. Urine output 15 mL per hour since midnight.

1000. Repeat chemistries: potassium 6.1 mEq/L, up from 4.2 at 0600. Phosphorus 7.2 mg/dL. Calcium 7.1 mg/dL. Uric acid 11.4 mg/dL. Creatinine 1.9 mg/dL, up from a baseline of 0.8.

CUE — Which finding is the cue that starts the clock?

1. The clean central line site · 2. The temperature of 38.6 °C with an absolute neutrophil count of 180/mm³ · 3. The oxygen saturation of 96 percent · 4. The report of feeling "a little off" Key: 2. Absent redness and purulence do not rule out infection here, they are expected.

ANALYZE — What explains the absence of localizing signs?

1. The infection is early and has not seeded · 2. There are too few neutrophils to generate an inflammatory response · 3. The chemotherapy is masking pain · 4. The patient is dehydrated Key: 2.

PRIORITIZE — Which problem is ranked first?

1. Tumor lysis syndrome, because the potassium is rising · 2. Febrile neutropenia, because its clock is one hour, with tumor lysis managed in parallel · 3. Acute kidney injury, because creatinine doubled · 4. Hypotension, because the blood pressure fell Key: 2. Two emergencies can run at once without either one waiting.

GENERATE SOLUTIONS — Which set is complete?

1. Antipyretic, then recheck the temperature in one hour · 2. Blood cultures, then broad-spectrum antibiotics within the hour, isotonic fluids, cardiac monitoring, repeat chemistries · 3. Antibiotics now and cultures after the fever breaks · 4. Fluids and monitoring only, pending the culture result Key: 2.

TAKE ACTION — What does the nurse do personally?

1. Delegate the blood culture draw to unlicensed assistive personnel · 2. Draw the cultures, hang the antibiotic, and delegate vital sign measurement and intake and output recording · 3. Delegate the antibiotic to the licensed practical nurse and leave the unit · 4. Wait for the provider to draw cultures Key: 2.

EVALUATE — What shows the plan worked?

1. The patient reports feeling better · 2. Antibiotic hung within the hour, heart rate and blood pressure stabilizing, potassium trending down, urine output above 30 mL per hour · 3. The temperature is unchanged at four hours · 4. The culture is reported as no growth at 24 hours Key: 2.

Margin noteno fever workup waits for a second temperature.

Takeawayin a neutropenic patient the fever is the whole assessment, and two emergencies can run at once without either one waiting.

Bowtie mechanics → BOOK 02 · P9. Protective precautions → BOOK 04 · P7. The delegation decision → BOOK 03 · P6.