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July Mailbag

Jan Shoenberger, MD and Stuart Swadron, MD, FRCPC
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No me gusta!

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EM:RAP 2019 July Written Summary 289 KB - PDF

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Dallas Holladay, DO -

Tiny point, contrary to the gender suggested by my name, I identify as female. Thanks for the shout out!

David G., M.D. -


I strongly disagree with your short segment this month on the supposed contraindication of obtaining rectal temps on neutropenic patients with potential fever.

Certainly, if the patient has a fever ascertained from a different source, there's no need to confirm it by rectal themometry. On the other hand, I've seen patients whose oral or tympanic (or forehead infrared) temp was slightly elevated (but below fever threshold), yet then had a markedly elevated rectal temp. (I think my record delta is 5 deg Farhenheit.)

I have long maintained and have taught on the national stage (I authored this year's EMA's two sepsis lectures and gave a sepsis update at the Kaiser National EM conference last year) that it strikes me as far more problematic to miss a fever in a neutropenic patient than to do a rectal temp. You quoted UpToDate, but didn't mention their concerns that "Compared with direct measurement of core body temperature...falsely low tympanic thermometry that might delay medical interventions have been observed in up to 21% of cases." [Temperature measurement: comparison of non-invasive methods used in adult critical care.
Farnell
J Clin Nurs. 2005;14(5):632.]

They also note, "Conversely, falsely high readings that might compel unnecessary interventions have been observed in up to 38% of pts whose temperatures were taken with a tympanic thermometer." [same reference].

While there is some science behind these warnings, as best I can tell, there is none behind the admonition to avoid rectal temps. The 2010 Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer (https://doi.org/10.1093/cid/cir073) states, "rectal temperature measurements...are avoided during neutropenia to prevent colonizing gut organisms from entering the surrounding mucosa and soft tissues." This exact phrase is used ad infinitum in various publications dating back decades as best I can tell, and never with a reference.

UpToDate states, "rectal thermometry is not recommended in neutropenic or thrombocytopenic patients because it may increase the risk for local mucosal trauma-induced bacteremia and bleeding." No reference is given, and I would agree with your listener that this defies common sense as gently inserting a lubed 3-4mm, smooth plastic thermometer into a patient's rectum is no doubt far less traumatic than that same patient having a bowel movement, yet no one is advocating aggressive bowel softening in these patients to avoid "local mucosal trauma-induced bacteremia."

When I first talked on sepsis at a national conference several years ago, I personally researched this topic, gave it to a medical librarian to research, and also took it up with my hospital's chief of oncology. No one could provide any reference for this prohibition, but could only reiterate that this is what is always taught.

That said, to avoid controversy, I perform the rectal temp myself, make sure I have plenty of lube, do it gently, and then record the temperature in the EMR as either an oral one or as one without a source.

J. B. L., M.D. -

Hi Stu - miss you here in Israel. No one likes snide comments from consultants ,but they are definetly correct sometimes. I once had a patient with abdominal pain who was neutropenic. I called a surgical consult, and the surgeon on call was also a proctologist. He did a rectal exam even so, and sure enough, the patient expired a few hours later from sepsis ( Ct was normal so it wasn't the abdominal process- although I do not remember why I called the consultant - this was 15 years ago)
Yea, could have been other reasons, but it pays to be careful - wiping one's botom doesn't usally go beyond the dentate line where absorption is much better,

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EM:RAP 2019 July Full episode audio for MD edition 192:37 min - 268 MB - M4AEM:RAP 2019 July German Edition Deutsche 103:01 min - 142 MB - MP3EM:RAP 2019 July Aussie Edition Australian 10:50 min - 15 MB - MP3EM:RAP 2019 July Farsi Edition Farsi 164:39 min - 226 MB - MP3EM:RAP 2019 July Canadian Edition Canadian 20:02 min - 28 MB - MP3EM:RAP 2019 July Spanish Edition Español 61:20 min - 84 MB - MP3EM:RAP 2019 July French Edition Français 24:38 min - 34 MB - MP3EM:RAP 2019 July Board Review Answers 237 KB - PDFEM:RAP 2019 July Board Review Questions 111 KB - PDFEMRAP 2019 July Individual MP3 250 MB - ZIPEM:RAP 2019 July Written Summary 289 KB - PDF

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