Nursing care of the child with neutropenic enterocolitis

A surgeon's predicament: Clinical predictors of surgery and mortality in neutropenic enterocolitis

BACKGROUND

Neutropenic enterocolitis is uncommon but potentially life-threatening, with the cornerstone of treatment being medical management (MM), and surgical intervention reserved for clinical deterioration or bowel perforation. We hypothesized that the Shock Index Pediatric Age-Adjusted (SIPA) is elevated in patients who are at greatest risk for surgical intervention and mortality. We also sought to identify computed tomography (CT) findings associated with surgical intervention and mortality.

METHODS

A single-center cancer registry was reviewed for neutropenic enterocolitis patients from 2006 -2018. Survival models compared patients with normal versus elevated SIPA throughout their hospitalizations for the time to surgical management (SM), as well as in-hospital mortality.

RESULTS

Seventy-four patients with neutropenic enterocolitis were identified; 7 underwent surgery. In-hospital mortality was 12% in MM and 29% in SM; mortality among patients with elevated SIPA was 4.7 times higher compared to those with normal SIPA (95% CI: 1.1, 19.83, p = 0.04). CT findings of bowel obstruction, pneumatosis, and a greater percentage of large bowel involvement were associated with surgical intervention (all ps < 0.05).

CONCLUSION

Select pre-operative CT findings were associated with need for operative management. Elevated SIPA was associated with increased mortality. Elevated SIPA in pediatric cancer patients with neutropenic enterocolitis may help to identify those with more severe disease and expedite beneficial interventions.

Typhilitis in the pediatric patient

Cancer statistics in children are promising as mortality rates consistently decrease, reflecting newer chemotherapeutic agents and the evolution of hematopoietic stem cell transplant. Typhilitis or neutropenic enterocolitis is a potentially life-threatening complication of cancer treatment often found in immunocompromised children receiving vigorous chemotherapeutic regimens and noted in children post-stem-cell transplant. Recent literature suggests a relationship between typhilitis and other types of cancers and immunocompromised illness occurring in both children and adults. The pathogenesis of typhilitis is poorly understood, with limited evidence regarding incidence. Nursing care and assessment of children receiving oncologic treatment requires vigilance and immediate response to prevent and manage complications, especially gastrointestinally related typhilitis.

Oncological emergencies in the pediatric intensive care unit

The overall 5-year survival rate of children with cancer has now reached 77%, an increase of about 45% in the past 25 years. Newer therapies, including hematopoietic cell transplantation and cutting edge chemotherapeutics evolving in the form of molecular and biological cell targeted agents, are being researched and developed and are responsible for the change in survival rates over time. Also, despite the national trend toward hospice and palliative care, children with chronic and life threatening illnesses, continue to die in the hospital setting, often in the intensive care unit. Previous studies of children with complications of cancer and its therapy document poor outcomes among those who do require intensive care. These trends are changing, however, currently leaving a hopeful, optimistic view of the outcome in children with cancer complications admitted to the pediatric intensive care unit. It is imperative that nurses and intensive care staff understand pediatric cancer and its potential emergent consequences in order to respond to the symptoms of life threatening events.

Pseudomembranous colitis associated with chemotherapy with 5-fluorouracil

Pseudomembranous colitis is frequently associated with antibiotics and more rarely with chemotherapeutic agents such as 5-fluorouracil. The objective of this study is to show that it is possible to confuse this infection with chemotherapy associated toxicity. We present a 54 year old woman who underwent surgery for colorectal cancer and in the first cycle of chemotherapy with 5-fluorouracil developed pseudomembranous colitis. We detected the toxin B of Clostridium difficile in stools and we began early antibiotic treatment. Thus, in patients with post chemotherapy neutropenia and diarrhoea that develop negatively, we have to rule out this infection.