ʻO ka Neutropenic Fever i ka wā o ka Chemotherapy a me ka mālama ʻana i ka maʻi maʻi ʻino¶

No ka poʻe e loaʻa ana i ka chemotherapy, hoʻomaʻamaʻa iwi iwi i manaʻo ʻia, a i ʻole ka hoʻololi ʻana o ke stem cell, ** ʻaʻole loa he "anu" wale nō ka maʻi maʻi maʻi: ʻo ia ka lāʻau lapaʻau weliweli i kapa ʻia ʻo Febrile Neutropenia (Neutropenic Fever). Hoʻopau ʻo Chemotherapy i ka puʻunaue wikiwiki ʻana i nā keʻokeʻo keʻokeʻo i kapa ʻia ʻo neutrophils, ka mea hoʻokele mua o ke kino e kūʻē i nā maʻi bacteria a me nā haʻi, ʻoi loa ma ka puka "nadir" (\(7\text{ a i }14\text{ days}\) ma hope o ka hoʻokomo ʻana i ka chemotherapy). Ke hāʻule ka helu neutrophil i ka ʻole a i ʻole kokoke i ka zero, hiki i nā hua bacteria kino ʻole e noho maoli ana i loko o ka waha, nā ʻōpū, a i ʻole ma ka ʻili a puni ke kikowaena venous port hiki ke komo i ke kahe koko a pālua i kēlā me kēia 20 mau minuke me ka hana ʻole ʻana i ka pus, ʻulaʻula, a me ka ʻū. Me ka mālama ʻole ʻia ma ka home no kekahi mau hola, piʻi koke ka neutropenic fever i ka fulminant. sepsis a me ka ha'alulu ma'i. Aia ke ola ma ka Golden Hour "Door-to-Antibiotic" Rule: hiki koke i kahi keʻena pilikia no laila e hoʻokomo ʻia nā lāʻau antibiotic intravenous broad-spectrum ** i loko o 60 mau minuke o ka hoʻāʻo ʻana, ʻaʻole hoʻi e uhi i ke kuni piʻi me ka acetaminophen (paracetamol) a i ʻole ibuprofen ma mua o ke kāhea ʻana i ka hui oncology.

E hana i kēia i kēia manawa¶

1. E nānā koke i kahi wela o ka waha (waha) a i ʻole tympanic/temporal a hoʻohana i ke kānāwai koʻikoʻi \(38.3^\circ\text{C}\) (\(101.0^\circ\text{F}\)) / \(38.0^\circ\text{C}\) (\(100.4^\circ\text{F}\)) rule. Wahi a ka American Infectious Diseases Oncology (AS), European Society of America (AS). ʻO ka Society for Medical Oncology (ESMO), a me nā alakaʻi UK NICE, Neutropenic Fever i wehewehe ʻia penei:
2. Ka mahana waha hoʻokahi o \(38.3^\circ\text{C}\) (\(101.0^\circ\text{F}\)) a ʻoi aku paha, OR
3. He mahana waha o \(38.0^\circ\text{C}\) (\(100.4^\circ\text{F}\)) a oi a'e paha e mau ana no 1 hola (a i 'ole ua ana 'elua ma kahi o 1 hola ma ke ka'awale).
4. *(E hoʻomanaʻo: ʻoi aku ka nui o nā hilinaʻi UK NHS a me nā kikowaena maʻi maʻi e hoʻohana i ka paepae heluhelu hoʻokahi ʻoi aku ka koʻikoʻi o \(38.0^\circ\text{C}\) [\(100.4^\circ\text{F}\)] hoʻokahi, a i ʻole *\(37.5^\circ\text{C}\) [\(99.5^\circ\text{F}\) ʻāpana ʻelua'; paepae.)
5. **E kāhea koke i kāu helu ulia pōpilikia inā loaʻa ka mea maʻi i ke anu/ʻoʻoleʻa, ʻūlū, huikau, pōkole o ka hanu, a i ʻole ke koko haʻahaʻa. helu pilikia ina he huliluli (rigors) ka mea ma'i, maule ke ku ana, he puuwai wikiwiki (\(>100\text{ bpm}\)), he koko systolic ma lalo o \(100\text{ mmHg}\), a he haikea paha, he pohihihi, a huikau paha ka mea ma'i, ina paha e heluhelu ana ko lakou thermometer normal or abnormally low (\(<36.0^}\)circ\text \(<96.8^\circ\text{F}\)), no ka mea, ʻo ka sepsis anu ke ʻano weliweli loa o ka haʻalulu septic.
6. Inā paʻa me ke kuni, e kelepona koke i kāu 24-hour Oncology Triage Line a hele pololei i ke Keʻena Emergency. Mai kali a hiki i nā hola keʻena kakahiaka. E kipaku koke i kekahi i ka mea maʻi i ka haukapila, a e noi aku i ke kauka oncologist e kelepona mua i ke keʻena hoʻāʻo o ka lumi ulia pōpilikia no laila ** mākaukau nā moʻomeheu koko a me nā lāʻau antibiotic intravenous i ka hiki ʻana mai**.
7. Mai hāʻawi i nā lāʻau hoʻohaʻahaʻa i ke kuni (ʻaʻohe acetaminophen, paracetamol, ibuprofen, a i ʻole aspirin) a mai hoʻohana i ka thermometer rectal. E ana i ka mahana ma lalo o ke alelo (oral) a i ʻole ma lalo o ka lima (axillary; e hoʻomaopopo i ka holo ʻana o nā heluhelu axillary ma kahi o \(0.5^\circ\text{C}\)[$0.9] haʻahaʻa ma mua o ka heluhelu ʻana ma mua o hoʻokahi o ka heluhelu ʻana. ʻO ka heluhelu underarm o \(37.8^\circ\text{C}\) [\(100.0^\circ\text{F}\)] ua like ia me ke kuni waha).
8. E kau i ka ma'i i ka mea ma'i i ka ma'i ma'i ma mua o ka hele 'ana i loko o ka lumi kali o ka 'Oihana Ho'opi'i. No ka mea, 'ane'ane 'ole ka pale o ka ma'i neutropenic, 'o ka noho wehe 'ole 'ana i loko o ke ke'ena kali ulia pōpilikia e pili ana i ka po'e ma'i he mea weliweli. E hōʻike koke i kāu "Chemotherapy Neutropenic Sepsis Alert Card" i ke kahu hoʻāʻo a noi aku e hoʻokomo koke ʻia i loko o kahi lumi hoʻokolokolo kaʻawale.
9. E nānā no nā ʻEha Nui ʻEmelika Oncologic Emergencies. ʻOiai e hoʻomākaukau ana no ka lawe ʻana, e nānā wikiwiki no Malignant Spinal Cord Compression (ʻeha hope hou me ka nāwaliwali o ka wāwae, ka ʻeha, a i ʻole ka pilikia o ka ʻōpū), ** Superior Vena Cava (SVC) Syndrome** (pehu ka maka/'ā'ī a me ka pōkole o ka hanu), **Tumor Lysis Syndrome, o nā lā hoʻomaka ʻana o ka ʻōpū o ka ʻōpū, ʻo ka maʻi ʻeleʻele i loko o ka ʻāʻī o ka ʻōpū. chemo), a me Hypercalcemia of Malignancy (makewai nui, mimi pinepine, constipation, a me ka huikau).

lāʻau hoʻoholo pilikia pilikia a me ka mālama ʻana i ka maʻi kanesa¶

E hoʻohana i kēia palapala holo kaʻa no ka hoʻāʻo ʻana i kekahi hōʻailona koʻikoʻi i loko o ka mea maʻi e mālama ana i ka maʻi maʻi maʻi a i ʻole i loko o 6 mau pule o ka chemotherapy.

flowchart TD
    Start["ʻO ka maʻi maʻi maʻi maʻi ma ke kemoterapi, immunotherapy,<br/>a i ʻole ka hoʻomohala ʻana i nā hōʻailona koʻikoʻi."] --> SepsisFlags{"KaʻAnuʻu Hana 1: E nānā i ka Septic Shock koke / Crisis Red Flags<br/>1. ʻO ka haʻalulu (rigors), ʻoiai ʻaʻohe wela kiʻekiʻe?<br/>2. Hypothermia: Ka wela <36.0°C (96.8°F)?<br/>3. ʻO ka poniuniu, maule, huikau, a i ʻole ka haʻi ʻōlelo?<br/>4. Pōkole hanu, hanu wikiwiki, a ʻeha paha ka umauma?<br/>5. ʻO ka ʻulaʻula, ka pus, a i ʻole ka ʻeha ma luna o ka laina Port-a-Cath / PICC / Hickman?"}

    SepsisFlags -->|"ʻAe: Kekahi 1 makana"| Call911["CRITICAL ONCOLOGIC SEPSIS / CRISIS:<br/>1. E kelepona iā 911 / 112 / 999 koke no ke kaʻa kaʻa<br/>2. E haʻi aku i ka 'Chemotherapy Neutropenic Sepsis Emergency'<br/>3. Hoʻoikaika 60-Minute Puka-a-IV-Antibiotic Target<br/>4. E moe palahalaha (a i ole pololei ina ua pokole ka hanu); NPO"]

    SepsisFlags -->|"NO"| TempCheck{"KaʻAnuʻu 2: E nānā i ka wela o ka waha<br/>(ʻAʻole e hoʻohana i ka thermometer rectal)<br/>ʻO ka mahana> = 38.3 ° C (101.0 ° F) i hoʻokahi manawa <br/> OR > = 38.0 ° C (100.4 ° F) no 1 hola?"}

    TempCheck -->|"ʻAe: Ua hoʻokō ʻia ka paepae wela"| NeutFever["KAHIKI FEVER NEUTROPENIC:<br/>1. MAI hāʻawi iā Tylenol/paracetamol, ibuprofen, a i ʻole aspirin<br/>2. Kāhea i 24-hola Oncology Triage Line NOW oiai e haʻalele ana<br/>3. E kau i ka pale maka ma ka ma'i; e hele i ka 'Oihana Hoʻopilikia i kēia manawa<br/>4. Hōʻike i ke Kāleka Makaʻala Chemo ma ka hoʻāʻo ʻana: noi i ka hoʻokaʻawale +<br/> Koko Moʻomeheu (Port + Peripheral) & IV Antibiotic < 60 mins"]

    TempCheck -->|"NO: ʻAʻohe kuni a me nā hōʻailona sepsis"| OncEmerg{"KaʻAnuʻu Hana 3: E nānā i nā pilikia o ka maʻi maʻi ʻaʻai a me ka metabolic:<br/>A. ʻEha hou/ʻāʻī + nāwaliwali o ka wāwae, ʻeha, a i ʻole ka loli ʻana o ka ʻōpū?<br/>B. Pehu ka maka/'ā'ī/lima + ʻuʻu/ ʻehaʻeha e moe ana i lalo?<br/>C. Kemo hou loa (1-7 lā) + ʻeha, ʻeha, ʻeleʻele mimi?<br/>D. ʻO ka make wai nui, ka huikau, ka paʻapū, ka ʻeha iwi?"}

    OncEmerg -->|"A: ʻEha hope + hōʻailona neuro"| MSCC["HOʻOPIʻI ʻia ka ʻāʻī o ke kuamoʻo i manaʻo ʻia:<br/>Emergency Spine MRI + High-Dose IV Dexamethasone NOW"]

    OncEmerg -->|"B: pehu ka maka/ā'ī + dyspnea"| SVCS["SYNDROME SUPERIOR VENA CAVA (SVC) SYNDROME:<br/>Noho pololei (45-90 deg); ʻO ka ʻūhā ʻeha CT + mālama ʻo Oncology"]

    OncEmerg -->|"C a i ʻole D: Ka pilikia metabolic"| Metabolic["KA HOʻOPIʻI O KA PALAPALA A I ʻole HYPERCALCEMIA:<br/>Keʻena Kūikawā i kēia manawa no ka ECG, Electrolytes, & IV Fluids"]

Mahele 1: Hoʻomaopopo i ka Neutropenic Fever a me ka puka makani "Nadir".¶

1. He aha ka "Absolute Neutrophil Count" (ANC) a me ka Chemo Nadir?¶

Loaʻa i nā pūnaewele koko keʻokeʻo (leukocytes) kekahi mau ʻano cell, akā ʻo neutrophils ka mea mua e pepehi i ka bacteria. Hoʻohālikelike nā kauka i ka Absolute Neutrophil Count (ANC) ma ka hoʻonui ʻana i ka helu o ke koko keʻokeʻo holoʻokoʻa me ka pākēneka o nā neutrophils i ʻāpana ʻia ("segs") a me nā ʻāpana ʻokoʻa: - ANC Ola maʻamau: \(1,500\text{ a i }8,000\text{ nā pūnaewele no ka microliter }(\mu\text{L})\) (a i ʻole \(1.5\text{ a i }8.0 \times 10^9/\text{L}\)). - Neutropenia: ANC ma lalo \(1,500\text{ cells}/\mu\text{L}\) (\(<1.5 \times 10^9/\text{L}\)). - Neutropenia Koʻikoʻi (High Fever Risk): ANC ma lalo o \(500\text{ cell}/\mu\text{L}\) (\(<0.5 \times 10^9/\text{L}\)), a i ʻole Ma lalo o \(1,000\text{ cells}/\mu\text{L}\) i manaʻo ʻia e hāʻule ma lalo o \(508\) i loko o nā hola e hiki mai ana. - ** Neutropenia Kūlohelohe (Loaʻa Loa):** ANC ma lalo o \(100\text{ cells}/\mu\text{L}\) (\(<0.1 \times 10^9/\text{L}\)), maʻamau i ka wā o ka hoʻokomo ʻana i ka maʻi leukemia a i ʻole ka hoʻololi ʻana i ke kelepona.

I ka manawa hea ka "Nadir"? Ma hope o ka hoʻokomo ʻia ʻana o ka pōʻai chemotherapy intravenous maʻamau i ka lā 1, e ola ana nā neutrophils e holo nei i loko o ke koko no kekahi mau lā aʻo ka hale hana iwi iwi e hoʻopuʻu wale nei. No laila, piʻi ka helu o ke koko keʻokeʻo i kona wahi pōhaku haʻahaʻa loa (ka nadir) ma waena o La 7 a me ka lā 14 ma hope o ka chemotherapy (ʻoiai hiki ke loaʻa i kēlā me kēia manawa i kēlā me kēia lā i nā lāʻau lapaʻau i hoʻopaʻa ʻia i ka waha, radiation, a me nā maʻi maʻi hematologic e like me ka leukemia, lymphoma, a me ka myeloma lehulehu).

2. No ke aha i ʻike ʻole ʻia ai nā maʻi inā loaʻa iā ʻoe nā Zero Neutrophils¶

I loko o ke kanaka me ka ʻōnaehana pale maʻamau, ʻike ʻia kahi maʻi ma muli o ka ** miliona o nā neutrophils e holo wikiwiki i ka pūnaewele a make**, e hana ana i ka nahu melemele mānoanoa, ʻulaʻula pehu ka ʻili, ʻeha ka ʻāʻī, a i ʻole nā ʻāpana keʻokeʻo ma ka pahu X-ray: - ʻAʻohe Neutrophils = ʻAʻohe Pus a ʻAʻohe Hōʻailona Kūlana: I kahi maʻi neutropenic koʻikoʻi: - Hiki i ka ma'i ma'i ma'i ma'i ke ho'oulu i ka zero cough, zero phlegm, a me ka x-ray akaka loa o ka umauma, e hō'ike ana i ke kuni a me ka hanu wikiwiki iki. - Hiki i ka ma'i 'ao'ao mimi (urosepsis) ko'iko'i ke kumu i ka a'e 'ole i ka mimi a hō'ike mai i ka a'e ke'oke'o ke'oke'o (pyuria) ma ka mimi dipstick, me ke kuni wale no. - Hiki ke hōʻike ʻia ka ** ʻili a i ʻole perirectal cellulitis ** e pili ana i ka anus a i ʻole ke awa venous waena e hōʻike i ka zero pus a i ʻole fluctuant abscess, e hōʻike ana me ka mehana maʻemaʻe, ka ʻulaʻula ʻulaʻula, a i ʻole ka ʻoluʻolu ma ka ʻaoʻao o ke kuni. - Ka ʻōlelo aʻoaʻo no nā Corticosteroids e uhi ana i ke kuni: Nui nā poʻe maʻi maʻi kanesa e lawe i kēlā me kēia lā a i kēlā me kēia pule dexamethasone a i ʻole prednisone (no ka pehu ʻana o ka lolo, lymphoma, myeloma lehulehu, nā hopena ʻaoʻao immunotherapy, a i ʻole nausea). Kāohi ikaika nā corticosteroids i ka thermostat hypothalamus o ka lolo. ** Hiki i ka mea maʻi e lawe ana i ka dexamethasone ke loaʻa i ka neutropenic bloodstream sepsis me ka mahana maʻamau o \(37.0^\circ\text{C}\) (\(98.6^\circ\text{F}\)). I nā poʻe maʻi e hoʻohana ana i nā steroids, e nānā ma kahi o ** nā haʻalulu (rigors), luhi hikiwawe, huikau haʻahaʻa, poniuniu, hāʻule o ka naʻau ma lalo o \(}\)6 (\(96.8^\circ\text{F}\))**.

3. Ka "60-Minute Door-to-Needle Antibiotic Rule"¶

Ke komo ka bacteria i loko o ke koko o ka mea maʻi me ka neutrophils ʻole (pinepine ʻo Gram-negative rods e like me Escherichia coli, Klebsiella pneumoniae, a i ʻole Pseudomonas aeruginosa e unuhi ana ma waena o nā ʻeha waha i hoʻopōʻino ʻia e ka chemotherapy [mucositis] a i ʻole lining intestinal, a i ʻole Grampositive like S. Streptococcus mai nā catheters venous waena), piʻi nui ka make me kēlā me kēia hola o ka lohi. - Ke Manaʻo Haukapila International: ʻO nā alakaʻi mai ASCO, IDSA, ESMO, ka Surviving Sepsis Campaign, a me UK NICE (CG151) kauoha i kēlā me kēia keʻena pilikia e lawelawe i ka nui mua o ka empiric anti-pseudomonal intravenous beta-lactam antibiotic (e like me cefepime, piperacillin-tazobactam/Tazobactam] He 60 mau minuke o ka mea maʻi e heʻe ana ma ka puka o ka haukapila, me ke kali ʻole no ka hoʻi ʻana mai o ka hopena o ka helu ʻana o ke koko keʻokeʻo keʻokeʻo (CBC) inā he neutropenia. - He aha ka mea e hana ʻia i kēlā mau minuke 60 mua: Huki koke nā kahu hānai ** ʻelua pūʻulu o nā moʻomeheu koko (hoʻokahi set i kaha ʻia ma kēlā me kēia lumen o ka mea maʻi i hoʻokomo ʻia Port-a-Cath, laina PICC, a i ʻole Hickman catheter, a hoʻokahi set i huki ʻia mai kahi vein lima ʻaoʻao), e kaha i ka Complete Blood Count (CBC a me ka ʻokoʻa o ke koko, ** ka pae koko ma hope koke o ke kau ʻana o ke koko, ** me ka pae koko ʻokoʻa ma hope o ka pae ʻana o ke koko, ** ka pae koko IV, ka lāʻau antibiotic a me ka ʻokoʻa). huki. - High-Risk vs. Low-Risk Triage (The MASCC Score): I ka holo ʻana o ka maʻi antibiotic IV mua, e helu ka poʻe oncologists a me nā kauka ulia pōpilikia i ka Multinational Association for Supportive Care in Cancer (MASCC) Risk Index a me CISNE score e hoʻoholo ai inā pono ka mea maʻi e noho i loko o kahi lumi hoʻokaʻawale inpatient (pono ke cell no ka leukemia, ka maʻi koko, ka maʻi maʻi maʻi, ka maʻi koko, ka ʻeha koko, ka ʻeha haʻahaʻa. a i ʻole mucositis koʻikoʻi) a i ʻole hiki ke hoʻololi i ka lāʻau lapaʻau e nānā pono ʻia.

Mahele 2: ʻIke ʻana i nā ʻelima ʻē aʻe e hoʻoweliweli i ke ola oncologic emergencies¶

ʻOiai ke loaʻa ʻole ka maʻi kuni i ka mea maʻi maʻi maʻi, hiki i ka maʻi maʻi maʻi a me ka mālama ʻana i ka maʻi kanesa hou (chemotherapy, radiation, a me immune checkpoint inhibitors) hiki ke hoʻoulu i ʻelima mau pilikia kino a i ʻole metabolic e pono ai ke mālama koke i ka ʻoihana pilikia.

ʻO ka mālama mua ʻana o ka haukapila i ka wā e hoʻomākaukau ai no ka Oihana Hoʻopilikia¶

KaʻAnuʻu 1: Pehea e lawe ai i kahi wela kūpono i kahi maʻi Chemotherapy¶

1. E hoʻohana i ka waha kikohoʻe (ma lalo o ke alelo), tympanic (pepeiao), a i ʻole ke aʻa kino kino (lae).
2. Inā inu wale ka mea maʻi i ke kī wela a i ʻole ka wai hau, e kali 15 a 20 mau minuke ma mua o ka lawe ʻana i ka wela waha i ʻole e hoʻololi hewa ʻia ka heluhelu ʻana.
3. Paʻa loa: Mai hoʻohana i ka Thermometer Rectal.
4. Hoʻopōʻino ke kemoterapi i nā pūnaewele mucosal puʻunaue wikiwiki e hoʻopaʻa ana i ka ʻāpana ʻōpū holoʻokoʻa mai ka waha a hiki i ka anus (mucositis). ʻO ka hoʻokuʻu ʻana i kahi wela wela (a i ʻole suppository, enema, a i ʻole tampon) i loko o ka rectum hiki ke hana i kahi waimaka microscopic i loko o ka lining rectal fragile, e ʻae ai i nā miliona o E. coli a me anaerobic gut bacteria e komo koke i loko o ke koko (bacteremia) a e hoʻoulu ai i kahi ʻōpū perirectal pōʻino a i ʻole ke kahe ʻana o ke koko inā he haʻahaʻa nā platelets (thrombocytopenia).

KaʻAnuʻu Hana 2: E nānā i ka "Hidden Five" kahua komo maʻi¶

ʻOiai e kamaʻilio ana me ke kahu oncology triage a i ʻole ke kali ʻana i ka lawe ʻana, e nānā pono i kēia mau wahi ʻelima (ʻaʻole e ʻomi, pop, a ʻeha paha i kekahi ʻeha) a hōʻike i kāu mea e ʻike ai: 1. Mea Hana Kūwaena Venous (Port-a-Cath, PICC Line, a i ʻole Hickman Tunnelled Catheter): E nānā i ka ʻili ma luna o ke awa o ka umauma a i ʻole ka laina lima PICC me ka ʻole o ka ʻili ʻana i ka ʻaʻahu ʻālohilohi. Aia kekahi ** ʻulaʻula, pehu, mahana, ʻoluʻolu, a i ʻole ʻāpala melemele** ma ke ala ala? Ua hoʻomaka ʻia ke kuni a i ʻole ka haʻalulu ʻana ** i loko o 30 a 60 mau minuke ma hope o ka holoi ʻana a i ʻole ka hoʻohana ʻana i ke awa**? (He hōʻailona maʻamau o kahi lumen catheter colonized; pono nā limahana o ka haukapila e huki i nā moʻomeheu koko mai ke awa *ma mua o ka hoʻoholo ʻana pehea e mālama ai.) 2. Wā, Puʻu, a me Puʻu (Mucositis Oral): E hoʻomālamalama i ke kukui kelepona i loko o ka waha. Aia nā ʻeha ʻulaʻula ʻeha, nā ʻōpala e like me ka curd keʻokeʻo (thrush / candidiasis), kahe koko, a i ʻole ka paʻakikī o ka ʻai ʻana i ka wai? 3. Nā Māmā a me ka Hanu ʻana: E helu i ka nui o ka hanu ʻana o ka mea maʻi i loko o 60 kekona i ka hoʻomaha ʻana (ʻo ka hanu hanu ma luna o 20 a 22 mau hanu i kēlā me kēia minuke he hōʻailona hōʻailona mua o ka maʻi maʻi a i ʻole ka maʻi maʻi me ka ʻole o ka maʻi) a nānā i kahi oximeter pulse manamana lima inā loaʻa. 4. Wāhi ʻōpū a me Perirectal: E nīnau i ka mea maʻi inā loaʻa iā lākou kekahi ʻeha ʻōpū ma ka ʻaoʻao ʻākau (typhlitis) a i ʻole kekahi ʻeha, wela, palupalu paha a puni ka anus a i ʻole iwi huelo i ka wā e noho ai a e hele ana paha ** (perianal cellulitis kahi kumu huna o nā maʻi Gram-negative a me anaerobic anaerobic e hoʻoweliweli ana i ke ola). 5. Urine a me ka ʻili: E nīnau inā ʻoluʻolu ʻole ka mimi ʻana, ke ʻano ohu a ʻulaʻula paha, a i ʻole ua emi nui ka leo i nā hola he 12 i hala.

KaʻAnuʻu 3: Hoʻoponopono i ka Thrombocytopenia (Low Platelets) i ka manawa like¶

Ma muli o ka hoʻopau ʻana o ka chemotherapy i ka iwi iwi holoʻokoʻa, ʻo ka mea maʻi me nā keʻokeʻo keʻokeʻo haʻahaʻa (neutropenia) loaʻa pinepine nā platelets haʻahaʻa haʻahaʻa haʻahaʻa (thrombocytopenia, ʻoi aku ka nui inā hāʻule nā platelets ma lalo o \(10,000\text{ a i }20,000/\mu\text{L}\)) i ka manawa like: - E nānā i ka ʻili o nā ʻūhā, nā kuʻekuʻe wāwae, a me nā lima no nā kiko ʻulaʻula liʻiliʻi ʻulaʻula a i ʻole poni ʻeleʻele ʻaʻole i mae ke kaomi (petechiae), nā ʻeha ʻeleʻele i wehewehe ʻole ʻia (ecchymoses), a i ʻole nā ʻōpala koko i loko o ka waha (purpura pulu). - Inā he koko ihu a he ʻaʻa paha ka mea maʻi ma ka ʻaoʻao o ke kuni, e hoʻonoho pololei iā lākou e hilinaʻi ana i mua, e kuʻi mau i ka ihu haʻahaʻa palupalu no 20 mau minuke (e nānā ihu koko), a e haʻi koke i ke keʻena pilikia no ka mea e pono ai lākou i ka ** platelet transfusion ** me ka ʻaoʻao o kā lākou mau lāʻau antibiotic IV.

KaʻAnuʻu Hana 4: Makaʻala Kūikawā Kūikawā no ka Cell CAR-T a me nā maʻi Antibody Bispecific (CRS a me ICANS)¶

Inā loaʻa koke i kahi maʻi CAR-T cell therapy (chimeric antigen receptor T-cell therapy) a i ʻole kahi bispecific T-cell engager antibody no ka maʻi leukemia, lymphoma, a i ʻole myeloma lehulehu i loko o nā pule he 4 i hala iho nei, ʻelua mau kumu hoʻoweliweli i ke kuni hikiwawe: 1. Neutropenic Bacterial Sepsis (koi koke i 60-minuke IV antibiotic), AND 2. Cytokine Release Syndrome (CRS) a me Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS): ʻO ka hoʻoulu ʻana o ka immune nui e hoʻoulu ai i ke kuni kiʻekiʻe (\(>38.0^\circ\text{C}\) i \(40.5^\circ\text{C}\)), hāʻule ke koko, haʻahaʻa oxygen, a i ʻole, hoʻololi ʻana i ka lima neurological, hoʻololi ʻana i ka lima neurological. hopu ʻia). - Ka Hana Pono: E hōʻike mau i ka CAR-T / Bispecific Wallet Card o ka mea maʻi ma ka hoʻokolokolo pilikia koke; ma waho aʻe o nā lāʻau ʻokoʻa ākea IV, pono kēia mau maʻi i ka hoʻokele wikiwiki ʻana i ka interleukin-6 receptor antagonist tocilizumab a/a i ʻole ** corticosteroids ** i hui pū ʻia me kā lākou kikowaena lapaʻau cellular.

Palapala kamaʻilio pololei no 911 / 112 / 999 a me Emergency Triage¶

Hōʻike nā haʻawina e loaʻa pinepine ka poʻe maʻi maʻi maʻi maʻi maʻi neutropenic i nā lohi weliweli ma nā wahi e kali ai i ka lumi pilikia nui ke ʻole ka mea maʻi a i ʻole ka lālā o ka ʻohana e haʻi i nā huaʻōlelo lapaʻau "Chemotherapy Neutropenic Sepsis: 60-Minute Antibiotic Window" ma ka hui mua loa. E hoʻohana i kēia huaʻōlelo no ka huaʻōlelo:

• I ke kelepona ʻana iā 911 / 112 / 999 (inā loaʻa ke anuanu, ʻūlū, pōkole o ka hanu, a huikau paha):

  *"Pono au i kahi kaʻa kaʻa ma [Exact Address] no ka mea i manaʻo ʻia ʻo Neutropenic Sepsis. ʻO ka mea maʻi he [Age]-makahiki [kāne/wahine] e hana ana i ka chemotherapy no [Type of Cancer], me kā lākou infusion chemotherapy hope loa ma [Date, X mau lā aku nei]. huikau], a ua hoʻokomo ʻia [ka laina Port-a-Cath / lima PICC].

• I ka piʻi ʻana i ka Desk Triage Desk Emergency (inā hōʻea ma ke kaʻa):

  *"Aia kēia mea maʻi ma ka chemotherapy ikaika (La [X] post-infusion, i loko o ka puka aniani) a he Neutropenic Fever o [X.X°C / XXX.X°F]. Eia [kāna] Oncology Neutropenic Sepsis Alert Card. Ma lalo o nā alakaʻi alakaʻi ASCO, IDSA, a me NICE, [ʻo ia] e koi aku i ka hoʻokaʻawale ʻana i ke koko, ke koko a me ka moʻomeheu palekana. * ʻ nā lāʻau ʻokoʻa i loko o 60 mau minuke o ka hoʻāʻo ʻana *."

• Inā aia ka mea maʻi ma ka Immunotherapy (Checkpoint Inhibitors like Pembrolizumab/Keytruda, Nivolumab/Opdivo, or Ipilimumab/Yervoy):

  *"Memo Koʻikoʻi no ka Triage: Loaʻa i kēia mea maʻi Cancer Immunotherapy ([Name of Drug]), ʻaʻole wale i ka chemotherapy kahiko. ʻO kā lākou mau hōʻailona paha he Immune-Related Adverse Event (irAE) e like me ka autoimmune pneumonitis, colitis, myocarditis, a i ʻole ka pilikia adrenal, e koi koke ana i ka oncology-dose ** i ka maʻi corticohigh no ka maʻi corticohigh.

He aha e hopu ai i loko o 2 mau minuke no ka Emergency Department Go-Bag¶

• **Ka "Chemotherapy / Immunotherapy Wallet Alert Card" o ka mea maʻi (e hōʻike ana i ke ʻano o ka lāʻau lapaʻau pololei, ka lā o ka pōʻai hope, ka helu kelepona o ka oncologist 24-hola/helu kelepona, a me ke ʻano awa).
• Kaleka hōʻike Port-a-Cath a i ʻole power-injectable port fob (e haʻi i nā kahu hānai pilikia inā he "Power-Injectable" ka pahu pahu no ka CT scan contrast a me ka nui o ka nila Huber [\(3/4\text{-inch}\) vs. \(1\text{-inch}\)] kūpono i ke awa).
• Kima Numbing (lidocaine/prilocaine EMLA cream) inā kauoha ʻia: kau ʻana i ka ʻili i hoʻopaʻa ʻia ma luna o ka umauma Port-a-Cath i uhi ʻia e ka ʻili iʻa i ka wā e holo ana i ke kaʻa i ka haukapila e hoʻopau i ka ʻili i loko o 30 mau minuke no laila ʻaʻole ʻeha ke komo ʻana i ke awa me ka nila Huber.
• ** ʻO nā lāʻau lapaʻau home āpau i kēia manawa** (ʻoi aku ka nui o nā lāʻau antibiotic prophylactic e like me levofloxacin a i ʻole trimethoprim-sulfamethoxazole, antifungals like fluconazole/posaconazole, antivirals like acyclovir, growth factor injections like pegfilgrastim [Neulasta] a i ʻole filgrastim [Neupogen], a me nā mea hoʻokahe koko).
• Kūpono kelepona a me kahi pale pale maʻemaʻe.

Ka pale ʻana i ka maʻi i kēlā me kēia lā i ka Chemotherapy Nadir (La 7 a 14)¶

ʻOiai ʻaʻohe mea e pale ai i ka 100 pākēneka o nā fevers neutropenic (no ka mea, ʻo ka hapa nui o nā maʻi e hele mai ana mai ka mea maʻi maʻamau o ka ʻōpala digestive), ma muli o kēia mau lula pili i nā hōʻike i kāu mau lā helu haʻahaʻa e hōʻemi ana i nā halemai hiki ke pale ʻia: 1. Ka mālama waha (Kaohi ʻana i ka Mucositis): Holoi i kou waha 4 manawa i ka lā (ma hope o kēlā me kēia ʻai ʻana a ma mua o ka moe ʻana) me ka wai ʻoluʻolu o **\(1/2\text{ teaspoon}\) paakai a me \(1/2\text{ teaspoon}\) baking soda (sodium bicarbonate) i hoʻoheheʻe ʻia i loko o \(240\text{ mL}\)$$\(\text{ wai mahana}**\). E hoʻohana i ka pulupulu niho palupalu loa, a e pale aku i ka waiʻona hoʻomaʻemaʻe kūʻai waha e maloʻo a pohā i ka waha. 2. Ka pale ʻana i ka ʻāʻī a me nā māwae anal: Kemotherapy a me nā lāʻau anti-nausea (e like me ka ondansetron/Zofran) ke kumu o ka paʻa paʻa. ʻO ka hoʻāʻo ʻana e hele i kahi moʻo paʻa e haehae i ka lining anal fragile (anal fissure), e hana ana i ka puka pololei no ka maʻi bacteria e komo i ke koko. E lawe i kāu mau mea hoʻomaʻemaʻe/laxatives o ka oncologist-i ʻōlelo ʻia i mua, inu i ka wai nui, a ʻaʻole loa e hoʻohana i nā suppositories rectal a enemas. 3. Ka meaʻai a me ka hoʻomaʻemaʻe lima: Holoi lima me ke kopa a me ka wai mahana no 20 kekona ma mua o ka ʻai ʻana a ma hope o ka hoʻohana ʻana i ka hale ʻauʻau. E kālua i nā ʻiʻo a pau, ka moa, ka iʻa, a me nā hua manu i ka mahana wela o loko, e holoi pono i nā huaʻai maka a me nā lau ʻai, a pale aku i ka waiu waiu ʻole, nā ʻōpuʻu maka, ka iʻa/sushi maka, a me nā meaʻai buffet i noho ma ka lumi wela. 4. E hoʻomaopopo iā Pegfilgrastim (Neulasta) Bone Pain vs. True Fever: Nui nā poʻe maʻi e loaʻa i ka hoʻoulu ʻana i ke koko keʻokeʻo (pegfilgrastim a i ʻole filgrastim, G-CSF) 24 mau hola ma hope o ka chemotherapy. Ke hana wikiwiki nei ka iwi iwi i nā neutrophils hou i nā lā 2 a hiki i ka 5 e hiki mai ana, ʻeha pinepine ka poʻe maʻi i ka ʻeha nui ma ko lākou pūhaka, ka iwi umauma, a me ke kua i lalo (hoʻomaha pinepine ʻia e ka loratadine [Claritin] inā ʻae ʻia e ka oncologist). Akā naʻe, mai manaʻo ʻoe he kuni ʻo \(38.0^\circ\text{C}\) (\(100.4^\circ\text{F}\)) a ʻoi aʻe paha "mai ka pana ʻana o Neulasta": e nānā mau i kou wela a kāhea koke i ka oncology no kekahi kuni.

Nīnau pinepine¶

No ke aha e ʻoi aku ka pōʻino o ka lawe ʻana iā Tylenol (acetaminophen / paracetamol) a i ʻole ibuprofen no ke kuni haʻahaʻa a i ʻole ke poʻo i ka wā o ka chemotherapy?¶

Ke hoʻohaʻahaʻa ka chemotherapy i kou mau keʻokeʻo keʻokeʻo (neutrophils), ʻaʻole hiki i kou kino ke hana i ka pus, ʻulaʻula, a i ʻole ka pehu kūloko i ka wā e hoʻouka mai ai ka bacteria, no laila ʻo ka piʻi ʻana o ke kuni ʻo ia ka hōʻailona ʻōlelo aʻoaʻo wale nō i hoʻomaka ai kahi maʻi koko weliweli. ʻO ka lawe ʻana i ka acetaminophen, ka paracetamol, ka ibuprofen, a i ʻole ka aspirin e hoʻohaʻahaʻa i kou wela ma ke ʻano hana no kekahi mau hola a hūnā i kēlā hōʻailona ʻōlelo aʻo ka nui o ka maʻi bacteria i kou koko. Mai lawe i kekahi lāʻau hōʻemi i ke kuni i ka wā o ka chemotherapy me ka nānā ʻole ʻana i kou wela ma mua a loaʻa ka ʻae ʻana mai kāu hui oncology.

He aha ka heluhelu ʻana o ka thermometer i helu ʻia ma ke ʻano he pilikia olakino i ka wā o ka chemotherapy?¶

Wahi a nā alakaʻi alakaʻi oncology honua (ASCO, IDSA, a me ESMO), ʻo ka neutropenic fever emergency he 38.3°C (101.0°F) a i ʻole ke kiʻekiʻe, A i ʻole he mahana waha o 38.0°C (100.4°F) a i ʻole ka lōʻihi no 1 piha hola. 100.4°F). Eia kekahi, inā haʻalulu ka mea maʻi chemotherapy, ʻūlū, ʻūlū, huikau, pōkole o ka hanu, a i ʻole kahi wela haʻahaʻa haʻahaʻa ma lalo o 36.0°C (96.8°F), he pilikia koke ia me ka heluhelu ʻole ʻana i ka thermometer kiʻekiʻe.

No ke aha e pāpā ʻia ai nā alakaʻi pilikia i ka hoʻohana ʻana i kahi thermometer rectal a i ʻole suppository rectal i loko o kahi mea maʻi chemotherapy?¶

Hoʻemi a hoʻonāwaliwali ʻo Chemotherapy i ka membrane mucous palupalu e pili ana i ka ʻāʻī a me ka ʻōpū i ka manawa hoʻokahi e hoʻohaʻahaʻa i nā keʻokeʻo keʻokeʻo e hakakā ana i ka maʻi a me nā platelets hoʻopaʻa koko. ʻO ka hoʻokomo ʻana i ka thermometer rectal, suppository, a i ʻole enema hiki ke ʻoki a haehae paha i ka paia ʻāʻī ʻāʻī, e hoʻokomo pololei i nā miliona o nā huakini ʻōpū i loko o ke kahe koko (no ka make ʻana o ka Gram-negative sepsis) a hoʻoulu i ke kahe koko.

No ke aha e koi ai ka ʻeha hope i ka mea maʻi maʻi i ka nānā wikiwiki ʻana no ka hoʻoemi ʻana i ke kuamoʻo?¶

Nui nā maʻi maʻi maʻamau (ʻo ia hoʻi ka umauma, ka prostate, ka māmā, ka puʻupaʻa, a me nā myeloma lehulehu) hiki ke laha i nā iwi o ka iwi kuamoʻo. Inā ulu ka waiho ʻana o ka maʻi maʻi i loko o ka ʻāʻī o ke kuamoʻo, ʻo ka hōʻailona mua loa ma luna o 90 pakeneka o nā maʻi he mea hou a i ʻole ka ʻeha ʻana o ke kua a i ʻole ka ʻāʻī (ʻoi aku ka maikaʻi o ka wā e moe paʻa ana ma kahi moe a ʻuʻu paha) i nā lā a i ʻole mau pule ma mua o ka nāwaliwali ʻana o nā wāwae. ʻO ka hopu ʻana i ka hoʻopaʻi ʻana i ke kuamoʻo maʻi i ka wā mua me kahi MRI pilikia a me ka nui o ka IV dexamethasone ʻoiai hiki i ka mea maʻi ke hele e mālama i ko lākou hiki ke hele a mālama i ka mana o ka ʻōpū.

Nānā ʻia nā kumu¶

• ** American Society of Clinical Oncology (ASCO) and Infectious Diseases Society of America (IDSA, United States):** Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: ASCO a me IDSA Clinical Practice Guideline Update (Taplitz et al., Journal of Clinical Oncology) a me *IDSA Guideline Guideline for Practice Antimics Clinical. ʻO nā maʻi neutropenic me ka maʻi maʻi * (Freifeld et al.).
• National Institute for Health and Care Excellence (NICE, United Kingdom): Neutropenic Sepsis: Prevention and Management in People with Cancer (NICE Clinical Guideline CG151, the 60-minute door-to-antibiotic mandate) a me Metastatic Spinal Cord Compression in Adults: Risk Assessment, Diagnosis and Management (NICE Guideline NG234).
• European Society for Medical Oncology (ESMO): Management of Febrile Neutropenia: ESMO Clinical Practice Guidelines (Klastersky et al., Annals of Oncology) a me ESMO Guidelines on Management of Toxicities from Immunotherapy.
• National Comprehensive Cancer Network (NCCN, United States): NCCN Clinical Practice Practice Guidelines in Oncology: Kāohi ʻana a me ka mālama ʻana i nā maʻi maʻi maʻi maʻi maʻi maʻi a me ka hoʻoponopono ʻana i nā mea ʻino pili i ka Immune Checkpoint Inhibitor-Related Toxicities.
• Oncology Nursing Society (ONS) & UK Oncology Nursing Society (UKONS): Acute Oncology Initial Management Guidelines and 24-Hour Triage Rapid Assessment Toolkit.

Nā alakaʻi pili¶

• ʻO Sepsis a me ka ʻike haʻalulu septic a me ka pane ulia pōpilikia
• ʻO ka maʻi Cauda equina a me nā hae ʻulaʻula e hoʻopiʻi ai i ka spinal cord
• Adrenal pilikia a me Addison's maʻi ulia pōpilikia
• ʻO ka pulmonary embolism a me ka thrombosis vein hohonu (DVT)
• ʻO ke koko hoʻoweliweli i ke koko ma ka hemophilia