Unwell immunocompromised person

Any person, 4 weeks to 15 years, presenting unwell with or without fever, who has recently (within 14 days) received chemotherapy or other potential cause of immunocompromise.

Escalate immediately as per local CERS protocol.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort Allocate to protective isolation space Review the patient's febrile neutropenia management plan if available

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG
IVC and/or pathology	Proceed to access the central venous access device (CVAD), if trained and/or insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present: give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL give antibiotics. See antibiotic management section

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Commence strict fluid input and fluid output monitoring

Glucose

Assessment

Intervention

BGL

Measure BGL. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose, 2 mL/kg by slow IV injection once only if IV access delayed, give: Up to 25 kg: glucagon 0.5 mg IM, once only 25 kg and over: glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Focused assessment

Focused assessment should not delay antibiotic administration.

Consider relevant focused assessment according to findings.

Precautions and notes

• All patients presenting with fever following anticancer therapy should be managed as neutropenic and receive empiric antibiotics, until proven otherwise.
• Patients with presumed sepsis are at high risk of clinical deterioration despite initial resuscitation with fluids and antibiotics.
• Do not wait for white cell count (WCC) or neutrophil count before commencing antibiotics.
• Some patients with serious infection may present without fever or with hypothermia.
• Bacteraemia is present in up to one-third of children with febrile neutropenia.

Interventions and diagnostics

Antibiotic management

Suspected febrile neutropenia with systemic compromise or shock: give antibiotics within 30 minutes if a medical or nurse practitioner is unavailable.

Suspected febrile neutropenia without systemic compromise or shock: give antibiotics within 60 minutes if a medical or nurse practitioner is unavailable.

Attempt blood cultures and sampling prior to giving antibiotics, but do not delay treatment.

Initial antibiotics

Select one:

• No known allergies
• Non-severe penicillin allergy
• Life-threatening or uncertain penicillin allergy

Gentamicin

Do not give gentamicin if patient has:

• pre-existing significant auditory impairment or vestibular condition
• history of hypersensitivity reaction to aminoglycoside
• myasthenia gravis
• history of aminoglycoside-induced vestibular or auditory toxicity, or first degree relative has history of same.

If the patient has any of the above contraindications, continue to give the other antibiotics and seek advice about gentamicin.

---

Analgesia

Select pain score:

• 1–3 (mild)
• 4–6 (moderate)
• 7–10 (severe)

Consider non-pharmacological pain relief (appendix).

---

Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

---

Procedural analgesia

For pain relief required during procedures only, not used to replace appropriate analgesia.

Sucrose 24%

• 1–18 months: give 1–2 mL orally per procedure
• Maximum dose:
  • 1–3 months: up to 5 mL in 24 hours
  • 3–18 months: up to 10 mL in 24 hours.

Repeat as needed up to the maximum dose.

---

Radiology

• If chest thought to be source or source is difficult to determine: CXR

---

Pathology

Attempt blood cultures and sampling prior to giving antibiotics, but do not delay treatment.

• FBC, UEC, LFT, VBG, Ca/Mg/PO4, group and hold, blood cultures
• Blood cultures: if the patient has a central venous access device in situ, it is recommended to take 1 set of blood cultures from each lumen (minimum of two sets collected).
• Urinalysis:
  • Patient who can void in the toilet: mid-stream urine
  • Patient who is not toilet trained: clean catch or catheter urine
  • Send for MC&S. Keep the sample refrigerated if transport is delayed.
• Consider using for specific fever sources: wound swab, sputum culture, stool culture and respiratory viral screen

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au