Jul 16, 2012
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My attending had this 90 something female with fever ; TMAX 103 x 3 days, AMS, no obvious source, and while waiting for labs/CXR to come back I took a peek at the CBC which showed a WBC of 9.4, and a Neutrophil % in the 80s-90s. I asked if this was significant, as she may not be able to mount a white count secondary to her age/comorbidities (which I don't remember). He said the neutrophil count is worthless and Bands would be more indicative, although our labs doesn't check for bands unless the WBC is high.

I always thought (as a guideline, not the law), that a high N% may mean bacterial infx, L% viral, Eosinophil% parasitic/allergic, and felt that this woman possibly couldn't mount a white count, but her diff was significant. I mean we still drew cultures and checked for a source, but I guess my quesiton is how important is the diff? How should I approach it and how much emphasis should I place on it? While we're on the subject, how do you approach bandemia and how serious is it really?

Thanks in advance!
 

Dr.McNinja

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Statistically, the neutrophil count isn't a good predictor of bacterial vs viral.
However, individual patients aren't necessarily statistics.

However, in that patient, without knowing more, a 9.4 with a 85% PMN count doesn't strike me as concerning.
 

dotcb

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Think most would treat for sepsis with broad spectrum antibiotics, including meningeal dosing, based on the full syndrome of fever, AMS, etc. rather than based on the left shift itself. That is, provided there was not an alternative explanation for the fever, AMS.
 

Arcan57

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I wouldn't jump to meningeal dosing unless the usual sources looked clean in a 90 yr. Torturing a demented NH dweller with a 20g to the epidural space seems unnecessarily cruel unless you have a really high suspicion.
 

EM_Rebuilder

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Yeah, we need to know the urine. A slight UTI seems to through the older generation for a loop.

Second, I would think maybe Flu.

Admission vs not... It would depend on how I get her acting in the EC. Sometimes getting the fever down will get them acting right, good family support, d/c home. If family insists, and patient cannot resume at home how she was, I would probably admit her.
 

gman33

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Yeah, we need to know the urine. A slight UTI seems to through the older generation for a loop.

Second, I would think maybe Flu.

Admission vs not... It would depend on how I get her acting in the EC. Sometimes getting the fever down will get them acting right, good family support, d/c home. If family insists, and patient cannot resume at home how she was, I would probably admit her.
You would even think about sending home a 90+ year old with 3 days of fever?
 

turkeyjerky

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Smart money is on urine.
Only one SIRS criteria listed so far.
Still not worried.
FYI, AMS is one of the SIRS criteria in the newest surviving sepsis guidelines.

To the OP, in general I don't pay attention the the WBC unless it's low, or high enough to make me think of leukemia.
 

Dr.McNinja

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FYI, AMS is one of the SIRS criteria in the newest surviving sepsis guidelines.
Not unless there's "hot off the press" criteria that I can't see.

It might be classified as end organ dysfunction, but in this population, it's less likely that and more likely delirium. And that's not a SIRS criteria, it's a sepsis v severe sepsis thing.
 

Bostonredsox

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Yeah, we need to know the urine. A slight UTI seems to through the older generation for a loop.

Second, I would think maybe Flu.

Admission vs not... It would depend on how I get her acting in the EC. Sometimes getting the fever down will get them acting right, good family support, d/c home. If family insists, and patient cannot resume at home how she was, I would probably admit her.
nonsense, you are all calling me for that admission. the only question is to where. floor/SDU/ICU. Need to know the code status and familys desire to treat aggressively with EGDT, assuming this patients is tachycardic and possibly tachypnic to meet Sepsis criteria, which as Mcninja has pointed out, have not been given. And encephalpathy is a sign of end organ damage as far as I am concerned, and yes I have seen the new updates to the guidelines. However, again, I agree with mcninja. An extremely high % of non septic elderly with no white count, a HR of 78, normal RR and a slight fever have AMS if the source is the urine. Not sure if there is data or a physiologic explanation for this but I see a much higher rate of AMS in UTI pts then in severe PNA pts.

But I agree with above, money is on the urine. encephalopathic elderly pts with leukocytosis or fever is UTI 9 times out of 10. Check the urine, xry the chest, check a FLU pcr and a lactate level and look for decubs/ulcers. If those are all clean, then ask the family if they want the LP or not, because thats what I am going to do when they come to whichever floor.
 
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