Adult Chemotherapy Induced Anaphylaxis Policy

Transcription

1 Adult Chemotherapy Induced Anaphylaxis Policy The Beatson West of Scotland Cancer Centre 1053 Great Western Road Glasgow G12 0YN Written by: Elaine Barr Authorised by: D.Dunlop, C. Forte Issue Number : 1 Date of Issue: April 2010 Approved by : CMG Review Date: April 2012 Review By: Senior Nurse Chemotherapy Anaphylaxis Guidelines April

2 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

3 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

4 Anaphylaxis is likely when ALL of the following 3 criteria are met Airway Breathing Circulation Disability Exposure 1. Sudden Onset & Rapid Progression of Symptoms 2. Life-Threatening Airway and/or Breathing and/or Circulation problems 3. Skin and/or mucosal changes 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 - 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 The patient is usually anxious and can experience a sense of impending doom - 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

5 Prevention Action Identify patients at increased risk of chemotherapy induced anaphylaxis by taking a full history of previous allergic reactions 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 Ascertain if any pre-treatment steroids have been taken; or are to be administered prior to chemotherapy 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. Rationale To identify patients at risk of allergic reaction thus minimising risk To allow early detection and intervention minimising adverse effects 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 Some Common Cytotoxic Drugs Likely to Cause Immediate Hypersensitivity Reactions:- High Risk Moderate to Low Risk Rare Risk Paclitaxel Carboplatin Cisplatin Rituximab Docetaxel Caelyx Trastuzumab Cetuximab Bevacizumab Anaphylaxis Guidelines April

6 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 2. Explain all care to the patient and their family 3. Assess the patients airway, breathing and circulation and level of consciousness 4. Initiate frequent vital signs including oxygen saturation 5. Recline the patient into a comfortable position 6. Summon medical and nursing assistance Rationale To prevent further exposure to the allergen and minimise any further adverse reaction To inform patient of what is happening and to help reduce anxiety To ensure patient is not developing a more severe reaction To monitor hypotension, tachycardia and respiratory status 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

7 Management of Anaphylaxis Anaphylaxis with cardiovascular collapse common manifestation, vasodilation and loss of plasma from blood compartment Action to be taken Rationale 1. Stop the infusion/injection of chemotherapy immediately, maintaining IV access To prevent further exposure to the allergen and minimise any further adverse reaction 2. Call the cardiac resuscitation team and commence CPR if necessary 3. Recline the patient into a May be helpful for patients with comfortable position hypotension. However, may be unhelpful for patients with breathing difficulties 4. Administer oxygen 10 15L/min To increase cell perfusion 5. Administer Adrenaline 1:1000 solution 0.5mL (500 micrograms) IM 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 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 ml should be used. Hartmanns solution or 0.9% saline are suitable leukoytriene release Counter histamine mediated vasodilation Recovery can be transient and sometimes several doses may be required Improve hypotension 10. Record vital signs and maintain accurate documentation 11. Obtain 10ml clotted blood minutes after and no later than 6 hours, for specific IgE antibody and mast cell tryptase 12. Admit patient at discretion of medical team To assess whether episode is a genuine anaphylactic reaction Repeat episode can occur 1 72 hours after clinical recovery Anaphylaxis Guidelines April

8 Other Concurrent Measures Action If bronchospam severe and does not respond to other treatment administer Salbutamol 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. Ensure the episode is accurately documented (to include sensitivity) in appropriate nursing and medical records Rationale To reduce bronchospam To reduce patient anxiety and promote wellbeing, by educating patients on delayed side effects and how to deal with them in the first instance 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

9 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

10 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 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 (4) Chlorphenamine (5) Hydrocortisone (IM or slow IV) (IM or slow IV) Adult or child more than 12 years 10 mg 200 mg Child 6 12 years 5 mg 100 mg Child 6 months to 6 years 2.5 mg 50 mg Child less than 6 months 250 micrograms/kg 25 mg Anaphylaxis Guidelines April

11 REPORTING OF CHEMOTHERAPY INDUCED ANAPHYLACTIC INCIDENT Patient Name Unit No DOB Dept/Ward Consultant Date & Time Diagnosis Cycle No Regimen 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

12 References Allwood M, Stanley A & Wright P (2002) The Cytotoxics Handbook 4 th Ed, Oxon: Radcliffe Medical Press Ltd Bateman J (2006) Anaphylaxis: clinical features, management and avoidance The Journal of Prescribing and Medicines Management 17, Bryant H (2007) Anaphylaxis: Recognition, Treatment and Education Emergency Nurse 15 (2), 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, Finney A & Rushton C (2007) Recognition and management of patients with anaphylaxis Nursing Standard 21 (37), Ingram P & Lavery I (2005) Peripheral intravenous therapy: key risks and implications for practice Nursing Standard 19 (46), Resuscitation Council UK (2008) Emergency Medical Treatment of Anaphylactic Reactions : Guidelines for healthcare providers www. Resus.org.uk accessed (June 2009) Anaphylaxis Guidelines April