IntroductionFebrile neutropenia (FN) is common in cancer patients receiving myelotoxic therapy. The procedures to treat FN are well established in oncology, but it is unclear whether management is adequate in the emergency department (ED).MethodsThis prospective, multicentre, observational study was carried out in 47 French EDs for 6 months. Patients were adults presenting at the ED with FN after myelotoxic treatment for cancer. Severity of infection was defined according to Bone criteria for severe sepsis and septic shock (SS/SSh) and risk was determined according to Multinational Association of Supportive Care in Cancer (MASCC) criteria. The end point was the implementation of guidelines. Management of patients with SS/SSh required: (i) adequate intravenous (IV) antimicrobial therapy for the first 90 min (broad-spectrum beta-lactam with or without an aminoglycoside); (ii) fluid challenge (500 mL); (iii) lactate measurement; (iv) at least one blood culture; and (v) hospitalization. Management of patients without SS/SSh required: (1) no initiation of granulocyte - cell stimulating factor (G-CSF); (2) adequate IV antimicrobial therapy (broad-spectrum beta-lactam) and hospitalization if the patient was high-risk according to MASCC criteria; (3) adequate oral antimicrobial therapy (quinolone or amoxicillin/clavulanate or cephalosporin) and hospital discharge if the patient was low-risk.Results198 patients were enrolled; 89 patients had SS/SSh, of whom 19 received adequate antimicrobial therapy within 90 min and 42 received appropriate fluid challenge. Blood cultures were obtained from 87 and lactate concentration was measured in 29. Overall, only 6 (7%) patients with SS/SSh received adequate management. Among 108 patients without SS/SSh, 38 (35%) were high-risk and 70 (65%) low-risk. In the high-risk group, adequate antimicrobial therapy was given to 31 patients, G-CSF was initiated in 4 and 35 were hospitalized. In the low-risk group, 4 patients received adequate oral antimicrobial therapy, IV antimicrobial therapy was prescribed in 59, G-CSF was initiated in 12 and six patients were discharged. Adequate management was given to 26/38 (68%) high-risk and 1/70 low-risk patients. Factors associated with adequate management were absence of SS/SSh (P = 0.0009) and high-risk according to MASCC criteria (P < 0.0001).ConclusionsIn this French sample of cancer patients presenting to the ED with FN, management was often inadequate and severity was under-evaluated in the critically ill.
Pour faire face à l'attentat terroriste multisite du 13 novembre 2015, une régulation médicale zonale des huit Samu de la région Île-de-France a été mise en place au Samu de Paris. Elle a permis, en utilisant une stratégie de sectorisation des moyens Smur et des ressources hospitalières, la médi-calisation des sites, la régulation et le transport par des équipes médicales de la majorité des victimes en urgence absolue. Des moyens Smur et des hôpitaux ont pu être gardés en réserve pour faire face à une aggravation de la situation (notamment sur le site du Bataclan) et à d'éventuelles autres attaques. L'analyse de cette expérience montre de nombreux points forts mais aussi des pistes d'amélioration utiles pour tous ceux qui seraient confrontés à un tel événement.Abstract To face the multisite terrorist attacks on November 13, 2015, a medical zonal regulation system was set up at the Samu de Paris in order to coordinate the 8 Samu of the Île-de-France region. This system, by using a sectorization strategy of the medical means (mobile intensive care unit [MICU]) and hospital resources, enabled on site medicalization, regulation and transportation by medical teams of most of the patients presenting immediate emergencies. MICU and hospitals were kept available in case the situation had worsened (especially on the Bataclan site) or other attacks had occurred. The analysis of this experience shows many strong points but also useful areas of improvement for all those who might face such event.
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