Content last updated on 11/11/02 with quite a bit of new information added!
 
 

"What Is Neutropenia?"

Cyndi Cramer, BA,RN,OCN

Critical Care, Oncology, & Pediatric Educator

RealNurseEd.com

One Contact Hour Self Learning Module

Objectives:

1.   Define Neutropenia.
2.   Calculate an ANC and explain its significance.
3.   Outline causes and risk factors for neutropenia.
4.   Identify clinical consequences of neutropenia.
5.   Describe management strategies for neutropenia.
 
 

What Is Neutropenia?
 
 


 
 

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When a patient’s immune system becomes compromised and is at increased risk for infection we look at more then the WBC’s (white blood cells). We actually look at the differential on the CBC and calculate the ANC (absolute neutrophil count). By doing this we are able to look at the precursors of the WBC’s. These are the "baby WBC’s" or immature blood cells. These are found in the patient’s bone marrow. This number will give us a more accurate measurement of a patient’s risk for infection.

To measure this we look at the neutrophils (sometimes also called segs or polys) and the bands. The following formula is used:

Example: Neutrophils = 50 % Bands = 8%

WBC = 4000

50 + 8 = 58% = 0.58 X 4000 = 2320 = ANC

(note: some lab CBCs will give you the WBC as 4 instead of 4000. You wouldn't see such a small number for the complete WBC--change it to 4000.  Talk to your lab so you can understand how they are printing out the CBC with differential if it isn't making sense to you.)

Neutrophils are the body’s first line of defense and work by:

They normally increase when there is an infection as part of the patient’s "immune defense system".

Bands are immature neutrophils.
 
 

So What Does This Mean?

According to the World Health Organization (WHO)—an ANC < 2000 = Neutropenia. Some sources push it a little further and don’t consider the patient to actually be neurtropenic until their ANC is < 1500.

This becomes significant for patients receiving treatments that cause these numbers to decrease even further (such as chemotherapy or radiation therapy). It is also significant in warning us that a patient is immunosuppressed and at risk for infection and unable to adequately call on their "immune defense system".

          Generally, we follow these guidelines: Neutropenia = ANC < 2000 (slight risk of infection)

Mild Neutropenia = ANC > 1000 & < 1500 (minimal risk of infection)

Moderate Neutropenia = ANC > 500 & < 1000 (moderate risk of infection)

Severe Neutropenia = ANC < 500 (severe risk of infection)

Chemotherapy is usually not given to a patient with an ANC < 1000 (but other circumstances may change this parameter)

So What Causes This?
          Go to the Neutropenia Support Association's webpage to get more information about neutropenia and learn about some non-cancer causes of neutropenia: http://www.neutropenia.ca/  This is a registered charity that was formed in 1989 that provides assistance to neutropenic patients and their families and raises money for education and research.

                                                   

So What Do We Look For?

If a patient is severely neutropenic—they may not show the "typical" signs of infection that we are used to looking for. This is because the body is not producing WBC’s. Normally, when we have an infection—the WBC’s increase and this is what causes the redness, pus, and swelling that we are all so familiar with.

The most reliable sign (and many times the only sign) will be a fever > 100.5 F (38 C). Find out what temperature your MDs consider to be "a fever". They do not all agree on what the "magic number" is. You don't want your patient to call them at 2 am and get yelled at for calling when they don't really have a fever. Then they might not call when the temperature is actually within this physician's parameter for fever.

And remember, if a patient experiences chills or rigors...this will make the temperature go up. Their temperature should be taken again!

Of course, if we do see any traditional signs or symptoms of infection in a patient at risk—we need to take them very seriously. We need to "round up the usual suspects":

Respiratory: Cough, SOB, crackles, rhonchi, wheezes

GU: Burning, frequency, dysuria, hematuria, cloudy urine, vaginal discharge

GI: Diarrhea, guiac positive stools

Skin & Mucous Membranes: Redness, tenderness, swelling, "fungal" white patches

Indwelling devices: IV lines and urinary catheters symptomatic for infection

Some folks will "act septic" and never even have positive blood cultures. We still treat them aggressively when they are neutropenic.

Some folks will continue to have fevers without any signs of infection and while their ANC is increasing to acceptable levels. In that case, we usually gradually remove the antibiotics and continue to closely assess the patient. (They may be having "drug fevers" or "tumor fevers"...but we need to err on the side of caution...)

Note: Studies have shown that patients with NHL (Non-Hodgkin's Leukemia) have an increased risk of neutropenic complications if:


"Prevention is Worth a Pound of Cure"

      Teach patients basic hygiene measures:       Controversial precautions include: To download the NCCN (National Comprehensive Cancer Network) treatment guidelines for fever and neutropenia in patients with cancer, go to:
(this is in a "layman friendly" format)
http://www.cancer.org/docroot/CRI/content/CRI_2_4_7x_NCCN_Fever_and_Neutropenia_Treatment_Guidelines_for_Patients_with_Cancer.asp

Go to the NCCN website and medical professionals can register (free) and view all of the NCCN Guidelines online or order a free CD with the 2001 guidelines: www.nccn.org


 

Education is Always a Good Thing!

Teach the patient and family to notify the nurse or physician at the first sign of any kind of infection (and be sure to teach them what those signs and symptoms are!)

Stress the importance of calling their doctor if they have a fever > 100.5 (or whatever parameter their physician considers reportable)—even if it’s the middle of the night! A severely neutropenic patient can become septic in a heartbeat. Not wanting to "bother" their doctor until the morning could have very serious consequences!
 
 

Is There Anything That Can Help?

Actually, we have made some significant strides in recent years in reducing the severity and length of neutropenia in patients at risk. Remember when we talked about how the neutrophils are the "precursors" to the WBC’s? Well, several years ago, some people invented something called a "Hematopoietic Growth Factors" (HGF) or "Colony Simulating Factors" (CSF) that stimulate these "baby WBC’s" to grow. This is a whole new area of treatments known as Biological Response Modifiers (BRM’s) or Biotherapy. The first of these were G-CSF (also known as filgrastim or Neupogen) from AMGEN and GM-CSF (also known as sargramostim or Leukine or Prokine) now from Berlex. There are some different FDA approvals for these two drugs. Contact your drug reps for more information. They are also the best people to talk with if you have any questions or problems about insurance reimbursement.

 Neupogen info  at: www.neupogen.com (Click to get info about G-CSF, ie Neupogen, from the manufacturers. Read the whole info page and the clickables to get some great info about fighting Neutropenia)


 Leukine info at: www.leukine.com (Click to get info about GM-CSF, ie Leukine, form the manufacturers. This has less approvals then Neupogen but is being used in research in other areas of oncology treatment that are very interesting)


We also have a new product: peg-filgrastim or Neulasta. This is from the people that make Neupogen. This is only given once (by SC injection) per chemotherapy cycle instead of daily. It's a "smart" drug. It looks at the patient's neutropenia profile and keeps working until they start improving. It was made with a bigger molecule that causes it to accomplish this slow release action.
Go to www.neulasta.com for more information from the manufacturer.


But the most important things that we can do are:

                                  What Are Out Patient's Treatment Goals?

Determine what your patient's actual goals are with treatment:

These all require different thought processes on the part of the patient, family, and you!
  So, understand what your patient's goals are. They can make a world of difference in their treatment options and how aggressive you will be with that treatment!

Neutropenia has, in the past, been a major contributor in the deaths of many immune compromised patients. But with new medications and astute assessment and interventions—those numbers have been greatly reduced in recent years. And now you can be an active soldier in the battle against neutropenia!
 

The American Cancer Society (ACS) and NCCN have teamed up to Provide Easy to Understand Information on Cancer Treatment Options. The guidelines include information on early detection and evaluation of cancer, staging and side effects of various treatments. Guidelines on Fever and  Neutropenia and are included at: http://www.cancer.org/docroot/ETO/ETO_10.asp?sitearea=ETO
 
 


Click here to take survey of people who have read this module--
THANK YOU!

Bibliography

ATAQ--Appropriate Treatment Assures Quality, an Oncology Nursing Society Initiative for Quality Cancer Care Neutropenia training project, Ponte Verde Beach, Florida, Sept. 23-26, 1999   Updated ATAQ conference, Tampa, Florida, November 9, 2002

Balducci L, Lyman GH, Ozer H. "Patients aged 70+ are at high risk for neutropenic infection and should receive hemopoietic growth factors when treated with moderately toxic chemotherapy",  Journal of Clinical Oncology, 19:1583-1585, 2001

Balducci L, et al, "Hematopoietic reserve in the older cancer patient: Clinical and economic considerations", Cancer Control, 7: 539-547, 2000

Bonadonna, G, et al, "Adjuvent cyclophosphamide, methotrexate, and fluorouracil in node-positive breast cancer: the results of 20 years of follow-up", The New England Journal of Medicine, 332:901-906, 1995

Carroll-Johnson, R.M., editor, Selected Topics in Chemotherapy Administration, Oncology Nursing Forum Magazine, Vol. 24, No. 1, Oncology Nursing Press, Philadelphia, PA, Jan/Feb 1997 supplement.

Fishman, M & Mrozek-Orlowski, M, editors, Cancer Chemotherapy Guidelines and Recommendations for Practice, 2nd edition, Oncology Nursing Press, Philadelphia, PA, 1999.

Gates, R.A., & Fink, R.M., Oncology Nursing Secrets, Mosby, St. Louis, MO, 1997.

Intragumtomchai, T, et al, study on pretreatment factos that predict neutropenic complications in NHL presented at Tampa ATAQ conference 11/02--article name unknown , Leukemia Lymphoma, 37: 351-360, 2000

Itano, J.K., Taoka, K.N., Core Curriculum for Oncology Nursing, 3rd edition, W.B. Saunders Company, Philadelphia, PA, 1998.

Jassak, PF, "Evidence Based Oncology Nursing Practice: Improving Patient Outcomes in the Next Millenium", Oncology Nursing Forum, 28 (2), 3-4, 2001

Kwak, LW, et al, "Prognostic significance of actual dose intensity in diffuse large-cell lymphoma: results of a tree-structured survival analysis", Journal of Clinical Oncology, 8:963-977, 1990

Neutropenia A-Z (Instructor's Manual), Thousand Oaks, CA, Amgen, Inc, 2002

"Neutropenia in Blood Disorders You Don't Often Hear About (March 3, 2001):http://www.neutropenia.ca/what/html

Schindler, L.W., The Immune System—How It Works, (NIH/NCI), US Dept. of Health and Human Services, April, 1996.

Wilson, B, "Dietary Recommendations For Neutropenic Patients", Seminars in Oncology Nursing, Vol 18, No 1, pp44-49, Feb, 2002

Yasko, J.M., editor, Nursing Management of Symptoms Associated With Chemotherapy, 4th edition, Meniscus Health Care Communications, Cynwyd, PA, 1998.

Biotherapy Slide Show, ONS Online, sponsored by RP Rorer Pharmaceuticals, www.rp-rorer.com/productinfo/slides/general-oncology/HTMLslides

Venous List, Ohio State University IV list-serv, www.venous@ohsu.com
 
 

Don’t forget to take the test and do the evaluation if you want contact hours…

This is a practice test. You should try and pass this one before taking the real test to submit for your certificate. To pass this test you will need at least 8 out of 10 correct. After passing this practice test scroll down for the real test to submit your score to receive your certificate by e-mail.



Question # 1 (True/False) Only cancer patients have to worry about neutropenia.

    A) True
    B) False

Question # 2 (True/False) Neutrophils are precursors to white blood cells.

    A) True
    B) False

Question # 3 (True/False) The Nadir is the lowest point that the patient's blood counts can get to after chemotherapy.

    A) True
    B) False

Question # 4 (True/False) The patient should wait to report fever until it is > 102 F.

    A) True
    B) False

Question # 5 (True/False) In a severely neutropenic patient - fever may be their only symptom of infection.

    A) True
    B) False

Question # 6 (Multiple Choice) A patient with an ANC of 750 is said to be:

    A) Mildly neutropenic
    B) Moderately neutropenic
    C) Severely neutropenic
    D) Not neutropenic at all

Question # 7 (Multiple Choice) Neutropenic precautions include:

    A) Good handwashing
    B) Good hygiene
    C) Avoiding exposure to people who are sick or have been exposed to infectious diseases.
    D) All of the above

Question # 8 (True/False) Avoiding fresh fruits and vegetables and plants when neutropenic is controversial.

    A) True
    B) False

Question # 9 (Multiple Choice) A medication that has made a significant improvement in the severity and length of neutropenia is:

    A) Neupogen
    B) Procrit
    C) Sargramostim
    D) All of the above

Question # 10 (Multiple Choice) Mr. "Neut" Gingrich has a WBC of 2500 with segs of 12% and bands of 3%. What is his ANC?

    A) 337500
    B) 1050
    C) 375
    D) None of the above

NOW that you have passed the practice test above
pass the real test and complete the feedback below to get
your certificate sent to you by e-mail. Good luck!

Question # 1 (True/False) Only cancer patients have to worry about neutropenia.
True
False

Question # 2 (True/False) Neutrophils are precursors to white blood cells.
True
False

Question # 3 (True/False) The Nadir is the lowest point that the patient's blood counts can get to after chemotherapy.
True
False

Question # 4 (True/False) The patient should wait to report fever until it is > 102 F.
True
False

Question # 5 (True/False) In a severely neutropenic patient - fever may be their only symptom of infection.
True
False

Question # 6 (Multiple Choice) A patient with an ANC of 750 is said to be:
A. Mildly neutropenic
B. Moderately neutropenic
C. Severely neutropenic
D. Not neutropenic at all

Question # 7 (Multiple Choice) Neutropenic precautions include:
A. Good handwashing
B. Good hygiene
C. Avoiding exposure to people who are sick or have been exposed to infectious diseases
D. All of the above

Question # 8 (True/False) Avoiding fresh fruits and vegetables and plants when neutropenic is controversial.
True
False

Question # 9 (Multiple Choice) A medication that has made a significant improvement in the severity and length of neutropenia is:
A. Neupogen
B. Procrit
C. Sargramostim
D. All of the above

Question # 10 (Multiple Choice) Mr. "Neut" Gingrich has a WBC of 2500 with segs of 12% and bands of 3%. What is his ANC?
A. 337500
B. 1050
C. 375
D. None of the above

RealNurseEd.com

(Cynthia F. Cramer, BA, RN, OCN)

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