Download Adult Chemotherapy Induced Anaphylaxis Policy

Adult Chemotherapy
Induced Anaphylaxis
Policy
The Beatson West of Scotland Cancer Centre
1053 Great Western Road
Glasgow
G12 0YN
Written by: Elaine Barr
Issue Number : 1
Approved by : CMG
Anaphylaxis Guidelines April 2010
Authorised by: D.Dunlop, C. Forte
Date of Issue: April 2010
Review Date: April 2012
Review By: Senior Nurse Chemotherapy
1
Anaphylaxis, Acute Hypersensitivity or Allergic
Reactions
Definition
There is no universally agreed definition of anaphylaxis and the following
definition is offered by the European Academy of Allergology and Clinical
Immunology Nomenclature Committee:‘Anaphylaxis is a severe, life-threatening, generalised or systemic
hypersensitivity reaction’
This is characterised by rapidly developing life-threatening airway and/or
breathing and/or circulation problems usually associated with skin and
mucosal changes.
Resuscitation Council (2008)
Anaphylactic Response
A hypersensitivity reaction can occur when the immune system is provoked by
an antigen such as a cytotoxic drug, stimulating the formation of certain IgE
antibodies that attach to receptors on mast cells and basophils. A subsequent
exposure to the same antigen will trigger these antibodies, causing
degranulation of the cell and thereby releasing chemical mediators such as
histamine, serotonin, slow-reacting substance of anaphylaxis (SRS-A), and
eosinophil chemotactic factor of anaphylaxis (ECF-A). When released from
cells into the circulatory system, the chemical mediators produce an
anaphylactic response.
Anaphylactoid reactions differ from anaphylactic reactions in that no prior
exposure to the agent is necessary to induce the response. The agent itself,
not the IgE antibodies, will bind directly to the surface of the cells, causing
direct degranulation and a release of mediators.
Anaphylactoid and
anaphylactic reactions have identical signs and symptoms and are treated in
the same manner.
Anaphylaxis Guidelines April 2010
2
Introduction
Anaphylaxis is a severe, systemic, rapid and life threatening allergic reaction
that presents as a medical emergency. It can be precipitated in susceptible
individuals by a wide range of substances, however, for the purpose of this
document, the substances are cytotoxic drugs and biological therapies.
Anaphylaxis requires rapid recognition, treatment and management by health
professionals.
Cancer chemotherapy drugs are foreign substances able to induce
anaphylaxis and reactions range from mild cutaneous symptoms to severe
respiratory distress and cardiovascular collapse.
This adverse/allergic
reaction can occur generally within seconds or minutes of drug administration
with features of an anaphylactic reaction. Nurses need to be aware of the
signs and symptoms of such reaction because if doctors are not immediately
available, nurses are responsible for not only recognising the symptoms of a
hypersensitivity reaction, but also for treating it promptly.
Guideline Development
This guideline/protocol has been developed to ensure prompt recognition and
management of anaphylactic reactions by health care professionals and to
ensure a consistent approach across the Beatson West of Scotland Cancer
Centre.
All health care professionals should understand the causes of
anaphylaxis, know how to diagnose it and be able to administer effective
treatment.
Recognition of an Anaphylactic Reaction
A diagnosis of an anaphylactic reaction is likely if a patient who is exposed to
a trigger (allergen) develops a sudden illness, usually within minutes of
exposure, with rapidly progressing skin changes and life-threatening airway
and/or breathing and/or circulation problems. The reaction is usually
unexpected.
The range of signs and symptoms vary and certain combinations of signs
make the diagnosis of an anaphylactic reaction more likely.
When
recognising and treating an acutely ill patient, a rational ABCDE, Airway,
Breathing, Circulation, Disability (relating to patients conscious level),
Exposure (relating to skin and mucosal changes) approach must be followed
and life-threatening problems treated as they are recognised.
Anaphylaxis Guidelines April 2010
3
Anaphylaxis is likely when ALL of the following 3 criteria are met
Airway
1. Sudden Onset &
Rapid Progression of
Symptoms
2. Life-Threatening
Airway and/or
Breathing and/or
Circulation problems
3. Skin and/or
mucosal changes
Breathing
Circulation
The patient will feel
and look unwell
An intravenous trigger
will cause a more
rapid onset of
reaction
Patients can have an
A, B or C problem or
any combination. Use
the ABCDE approach
to recognise these
Should be assessed
as part of the
exposure when using
the ABCDE approach
Often the first feature
and present in over
80% of anaphylactic
reactions
Disability
Exposure
The patient is usually
anxious and can
experience a ‘sense of
impending doom’
- Airway swelling e.g.
throat, tongue swelling
- Difficulty breathing and
swallowing & patient
feels that the throat is
closing up
- Hoarse voice
- stridor
- Shortness of breath
- Wheeze
- Patient becoming tired
- Confusion cause by
hypoxia
- Cyanosis
- Respiratory arrest
- Signs of shock, pale,
clammy
- Tachycardia
- Hypotension, feeling
faint, collapse
- Decreased conscious
level
- Loss of consciousness
- Myocardial Ischaemia
and - ECG changes
- Cardiac arrest
- Anxiety, Panic
- Decreased conscious
level caused by airway,
breathing or circulation
problems
- Skin, mucosal or
both skin and
mucosal changes
Erythema
Urticaria
Angioedema –
swelling of deeper
tissues e.g. eyes, lips,
mouth and throat
Subtle or dramatic
Anaphylaxis Guidelines April 2010
4
Prevention
Action
Identify patients at increased risk of
chemotherapy induced anaphylaxis
by taking a full history of previous
allergic reactions
Rationale
To identify patients at risk of allergic
reaction thus minimising risk
Provide the patient with appropriate
information and education to enable
them to identify signs of
chemotherapy induced anaphylaxis
and emphasise the need to report
these signs immediately if they occur
To allow early detection and
intervention minimising adverse
effects
Ascertain if any pre-treatment
steroids have been taken; or are to
be administered prior to
chemotherapy
To identify concurrent measures that
may or may not be required if a
chemotherapy induced anaphylactic
reaction occurs (i.e. has the patient
had dexamethasone as part of prechemotherapy anti-emetic)
To allow early detection and
minimising adverse effects
Prior to administration of
chemotherapy, nursing/medical staff
should be familiar with the likelihood
of the drug causing anaphylaxis and
have easy access to emergency
equipment and drugs.
Some Common Cytotoxic
Hypersensitivity Reactions:-
High Risk
Paclitaxel
Rituximab
Trastuzumab
Bevacizumab
Drugs
Likely
Moderate to Low Risk
Carboplatin
Docetaxel
Cetuximab
Anaphylaxis Guidelines April 2010
to
Cause
Immediate
Rare Risk
Cisplatin
Caelyx
5
Management of a Mild to Moderate Acute Hypersensitivity Reactions or
Allergic Reactions
Mild to Moderate Adverse Drug Reaction – slowly progressing peripheral
oedema or changes restricted to the skin e.g. urticaria
Action to be taken
1. Stop the infusion/injection of
chemotherapy immediately,
maintaining IV access
Rationale
To prevent further exposure to the
allergen and minimise any further
adverse reaction
2. Explain all care to the patient and
their family
To inform patient of what is
happening and to help reduce anxiety
3. Assess the patients airway,
breathing and circulation and level of
consciousness
To ensure patient is not developing a
more severe reaction
4. Initiate frequent vital signs
including oxygen saturation
To monitor hypotension, tachycardia
and respiratory status
5. Recline the patient into a
comfortable position
6. Summon medical and nursing
assistance
May be helpful for patients with
hypotension, however, may be
unhelpful for patients with breathing
difficulties
Ensures prompt support especially if
patients condition deteriorates
7. Never leave the patient alone
Risk of shock/severe reaction
8. Administer Chlorpheniramine
10mgs IV slowly
Counter histamine mediated
vasodilation
9. Administer hydrocortisone 100mgs
IV
10. Document allergic reaction fully
in the medical and nursing notes
Prevention
11. Monitor for 8 – 24 hours
Risk of early recurrence
12. Treat prophylactically for the next
treatment
Prevention
Anaphylaxis Guidelines April 2010
6
Management of Anaphylaxis
Anaphylaxis with cardiovascular collapse – common manifestation,
vasodilation and loss of plasma from blood compartment
Action to be taken
1. Stop the infusion/injection of
chemotherapy immediately,
maintaining IV access
2. Call the cardiac resuscitation team
and commence CPR if necessary
3. Recline the patient into a
comfortable position
4. Administer oxygen 10 – 15L/min
5. Administer Adrenaline 1:1000
solution 0.5mL (500 micrograms) IM
6. Administer Chlorphenamine 10 mg
IM/slow IV
7. Administer Hydrocortisone 200 mg
IM/slow IV
8. Repeat dose of Adrenaline only
after 5 minutes and if no clinical
improvement
9. If severe hypotension does not
respond rapidly to drug treatment, IV
fluids 500 – 1000 mL should be used.
Hartmanns solution or 0.9% saline
are suitable
10. Record vital signs and maintain
accurate documentation
11. Obtain 10ml clotted blood 45 – 60
minutes after and no later than 6
hours, for specific IgE antibody and
mast cell tryptase
12. Admit patient – at discretion of
medical team
Anaphylaxis Guidelines April 2010
Rationale
To prevent further exposure to the
allergen and minimise any further
adverse reaction
May be helpful for patients with
hypotension. However,
may be
unhelpful for patients with breathing
difficulties
To increase cell perfusion
Alpha-receptor agonist, it reverses
peripheral vasodilation and reduces
oedema. Its beta-receptor activity
dilates the airways, increases the
force of the myocardial contraction
and suppresses histamine and
leukoytriene release
Counter histamine mediated
vasodilation
Recovery can be transient and
sometimes several doses may be
required
Improve hypotension
To assess whether episode is a
genuine anaphylactic reaction
Repeat episode can occur 1 – 72
hours after clinical recovery
7
Other Concurrent Measures
Action
If bronchospam severe and does not
respond to other treatment –
administer Salbutamol
Rationale
To reduce bronchospam
Provide support to the patient and
their family. Display a calm,
competent and confident disposition.
Reassure and explain to the patient
and any relatives what is being done
and what should be expected to
happen shortly.
To reduce patient anxiety and
promote wellbeing, by educating
patients on delayed side effects and
how to deal with them in the first
instance
Ensure the episode is accurately
documented (to include sensitivity) in
appropriate nursing and medical
records
To meet legal requirements and
prevent/minimise future problems
Differential Diagnosis
Life threatening conditions:Asthma – can present with similar symptoms and signs to anaphylaxis,
particularly in children.
Septic Shock – hypotension, usually in association with a temperature > 38C
or < 36C. There is an increased risk if central venous access has been used
recently.
Non life threatening conditions:•
•
•
•
Vasovagal episode
Panic attack
Breath holding in a child
Idiopathic (non-allergic) urticaria or angioedema
Seek help early if there are any doubts about the diagnosis
Anaphylaxis Guidelines April 2010
8
Education
Anaphylaxis can be fatal and therefore healthcare workers require regular
training in recognising, treating and managing anaphylaxis.
Patients should be given appropriate information and education to enable
them to identify signs of chemotherapy induced anaphylaxis and emphasise
the need to report these signs immediately if the occur.
Anaphylaxis Guidelines April 2010
9
Management of Anaphylaxis
This algorithm has been taken from the guideline on Emergency Treatment of Anaphylactic
reactions: Guidelines for healthcare providers, January 2008
Anaphylactic Reaction
Airway, Breathing, Circulation, Disability, Exposure
Diagnosis – look for:
• Acute onset of illness
• Life-threatening Airway and/or Breathing
and/or circulation problems (1)
• And usually skin changes
•
•
•
Call for help
Lie patient flat
Raise patients legs
Adrenaline (2)
•
•
•
•
•
When skills and equipment available
Establish airway
High flow oxygen
Monitor:
IV fluid challenge (3)
Pulse Oximetry
Chlorphenamine (4)
ECG
Hydrocortisone (5)
Blood Pressure
______________________________________________________________
1. Life-threatening problems:
Airway:
swelling, hoarseness, stridor
Breathing:
rapid breathing, wheeze, fatigue, cyanosis, Sp02 < 92%, confusion
Circulation:
pale, clammy, low blood pressure, faintness, drowsy/coma
2. Adrenaline (give IM unless experienced with IV
adrenaline) IM doses of 1:1000 adrenaline (repeat
after 5 min if no better)
• Adult
500 micrograms IM (0.5 mL)
• Child > 12 years
500 micrograms IM (0.5 mL)
• Child 6 – 12 years 300 micrograms IM (0.3 mL)
• Child < 6 years
150 micrograms IM (0.15 mL)
3. IV Fluid Challenge:
Adult – 500 – 1000 mL
Child – crystalloid 20 mL/kg
Stop IV colloid if this might
be the cause of anaphylaxis
Adrenaline IV to be given only by experienced
specialists. Titrate: Adults 50 micrograms; Children 1
microgram/kg
Adult or child more than 12 years
Child 6 – 12 years
Child 6 months to 6 years
Child less than
6 months April 2010
Anaphylaxis
Guidelines
(4) Chlorphenamine
(IM or slow IV)
(5) Hydrocortisone
(IM or slow IV)
10 mg
5 mg
2.5 mg
250 micrograms/kg
200 mg
100 mg
50 mg
25 mg
10
REPORTING OF CHEMOTHERAPY INDUCED ANAPHYLACTIC
INCIDENT
Patient Name
Dept/Ward
Unit No
Consultant
DOB
Date & Time
Diagnosis
Regimen
Cycle No
IV Access
Drugs
Administered
Amount of drug administered prior to onset of reaction (mls)
Symptoms
Experienced
Medical
Staff
Notified &
Present
Nursing
Action
Follow Up
Measures
A copy of this form must be filed in the medical notes
Print Name & Designation…………………………………………………
Signed…………………………………………………………………………
Anaphylaxis Guidelines April 2010
11
References
Allwood M, Stanley A & Wright P (2002) The Cytotoxics Handbook 4th Ed,
Oxon: Radcliffe Medical Press Ltd
Bateman J (2006) Anaphylaxis: clinical features, management and avoidance
The Journal of Prescribing and Medicines Management 17, 12 – 18
Bryant H (2007)
Anaphylaxis: Recognition, Treatment and Education
Emergency Nurse 15 (2), 24 – 28
Carr B & Burke C (2001) Outpatient Chemotherapy: Hypersensitivity and
Anaphylaxis: Oncology Nurses must know how to respond quickly and
correctly American Journal of Nursing 101 Supplement, 27 – 30
Finney A & Rushton C (2007) Recognition and management of patients with
anaphylaxis Nursing Standard 21 (37), 50 – 57
Ingram P & Lavery I (2005) Peripheral intravenous therapy: key risks and
implications for practice Nursing Standard 19 (46), 55 – 64
Resuscitation Council UK (2008) Emergency Medical Treatment of
Anaphylactic Reactions : Guidelines for healthcare providers
www.
Resus.org.uk accessed (June 2009)
Anaphylaxis Guidelines April 2010
12