The Case of the Swift Sepsis Response
This article was written in collaboration with Samantha Navarro, BSN, RN, BMTCN®.
Simon is a 72-year-old patient diagnosed with myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). He underwent an HLA-identical sibling peripheral blood stem cell transplantation with fludarabine and melphalan as conditioning chemotherapies before the procedure. Simon is now more than 12 days posttransplant but still neutropenic with an absolute neutrophil count (ANC) of 0. He has no signs of engraftment, is on total parenteral nutrition (TPN), and requires multiple blood transfusions and electrolytes through his central line catheter daily.
After receiving a morning report, you walk into Simon's room and notice he does not look as well as he did during the bedside shift report. He presents with new-onset shortness of breath that now requires 2 liters of nasal cannula, as well as tachycardia, hypotension not resolving with IV fluid boluses, and persistent fevers above 100.8°F. His serum lactate is 3.2 mmol/l.
What Would You Do?
Sepsis is one of the leading causes of mortality (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469653/) in neutropenic patients with cancer. Three risk factors increase a patient’s chance of developing posttransplant bacterial infections: mucositis, presence of a central line, and neutropenia. Unfortunately, Simon has two of the three risk factors. After meeting with the interprofessional care team, you consult the intensive care unit (ICU) for further management.
Patients are at highest risk for developing infections leading to sepsis during the posttransplant neutropenic phase, which usually occurs five to seven days after chemotherapy. Patients meet the criteria (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469653/) for sepsis when they present with neutropenia (ANC < 500 or ANC < 1,000 with a predicted decline within two days); fever; infectious symptoms, such as tachycardia and tachypnea; systolic blood pressure less than 100 mmHg; and a respiratory rate greater than or equal to 22. In addition, patients are at higher risk for septic shock (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469653/) if they require vasopressors to maintain a mean arterial pressure of 65 or higher and have a blood lactate greater than 2 mmol/l.
As Simon's nurse, you did a great job assessing the situation and escalating his care, but he still needs your help. Nurses are frontline fighters of sepsis, and timely administration of fluids and broad-spectrum antibiotics, both started within the first hour of sepsis (https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults/print), are crucial for optimal patient outcomes. Any delay could be detrimental.
The ICU team is already at the bedside with Simon. During the initial assessment, they began treating his sepsis with broad-spectrum antibiotics (https://www.sciencedirect.com/science/article/pii/S1658387617300560), including piperacillin and tazobactam as well as vancomycin. You drew multiple sets of blood cultures from his central line catheter and peripheral blood for comparison. For possible bacteremia, the care team discontinued Simon’s TPN but administered multiple fluid boluses to achieve normotension. Unfortunately, he maintained a blood pressure of 85/52 mmHg, a heart rate of 134, a respiratory rate of 31, and a temperature of 101.2°F. His blood lactate is now 4.1 mmol/l.
Simon now requires six liters of nasal cannula because the fluid boluses increased his oxygen needs. As the ICU progressed through assessment, the team concluded Simon would require further monitoring and extended stay in the ICU to control his hypotension and increasing oxygen requirements.
After few days in the ICU, Simon’s blood cultures in his central line and peripheral blood come back positive for multiple bacteria, including Klebsiella pneumoniae, Enterococcus faecalis, and Candida glabrata. Simon’s antibiotic treatment is escalated and tailored to those pathogens. After taking linezolid, his blood pressure returns to normal and he is transferred back to your transplant unit, where he finishes a 10-day course of antibiotics. The ICU team removes Simon’s central line catheter. He is engrafted about 10 days later and leaves the hospital without requiring oxygen support.