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 2010 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 Breathing Circulation Disability Exposure

1. Sudden Onset & The patient will feel The patient is usually
Rapid Progression of and look unwell anxious and can
Symptoms experience a ‘sense of
An intravenous trigger impending doom’
will cause a more
rapid onset of
reaction
2. Life-Threatening Patients can have an - Airway swelling e.g. - Shortness of breath - Signs of shock, pale, - Anxiety, Panic - Skin, mucosal or
Airway and/or A, B or C problem or throat, tongue swelling - Wheeze clammy - Decreased conscious both skin and
Breathing and/or any combination. Use - Difficulty breathing and - Patient becoming tired - Tachycardia level caused by airway, mucosal changes
Circulation problems the ABCDE approach swallowing & patient - Confusion cause by - Hypotension, feeling breathing or circulation
to recognise these feels that the throat is hypoxia faint, collapse problems
closing up - Cyanosis - Decreased conscious
- Hoarse voice - Respiratory arrest level
- stridor - Loss of consciousness
- Myocardial Ischaemia
and - ECG changes
- Cardiac arrest
3. Skin and/or Should be assessed Erythema
mucosal changes as part of the Urticaria
exposure when using Angioedema –
the ABCDE approach swelling of deeper
tissues e.g. eyes, lips,
Often the first feature mouth and throat
and present in over
80% of anaphylactic
reactions

Subtle or dramatic

Anaphylaxis Guidelines April 2010 4

Prevention

Action Rationale
Identify patients at increased risk of To identify patients at risk of allergic
chemotherapy induced anaphylaxis reaction thus minimising risk
by taking a full history of previous
allergic reactions

Provide the patient with appropriate To allow early detection and

information and education to enable intervention minimising adverse
them to identify signs of effects
chemotherapy induced anaphylaxis
and emphasise the need to report
these signs immediately if they occur

Ascertain if any pre-treatment To identify concurrent measures that

steroids have been taken; or are to may or may not be required if a
be administered prior to chemotherapy induced anaphylactic
chemotherapy reaction occurs (i.e. has the patient
had dexamethasone as part of pre-
chemotherapy anti-emetic)
Prior to administration of To allow early detection and
chemotherapy, nursing/medical staff minimising adverse effects
should be familiar with the likelihood
of the drug causing anaphylaxis and
have easy access to emergency
equipment and drugs.

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 2010 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 Rationale

1. Stop the infusion/injection of To prevent further exposure to the
chemotherapy immediately, allergen and minimise any further
maintaining IV access adverse reaction

2. Explain all care to the patient and To inform patient of what is

their family happening and to help reduce anxiety

3. Assess the patients airway, To ensure patient is not developing a

breathing and circulation and level of more severe reaction
consciousness

4. Initiate frequent vital signs To monitor hypotension, tachycardia

including oxygen saturation and respiratory status

5. Recline the patient into a May be helpful for patients with

comfortable position hypotension, however, may be
unhelpful for patients with breathing
difficulties
6. Summon medical and nursing Ensures prompt support especially if
assistance patients condition deteriorates

7. Never leave the patient alone Risk of shock/severe reaction

8. Administer Chlorpheniramine Counter histamine mediated

10mgs IV slowly vasodilation

9. Administer hydrocortisone 100mgs

IV

10. Document allergic reaction fully Prevention

in the medical and nursing notes

11. Monitor for 8 – 24 hours Risk of early recurrence

12. Treat prophylactically for the next Prevention

treatment

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 Rationale

1. Stop the infusion/injection of To prevent further exposure to the
chemotherapy immediately, allergen and minimise any further
maintaining IV access 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 Alpha-receptor agonist, it reverses
solution 0.5mL (500 micrograms) IM 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
6. Administer Chlorphenamine 10 mg Counter histamine mediated
IM/slow IV vasodilation
7. Administer Hydrocortisone 200 mg
IM/slow IV
8. Repeat dose of Adrenaline only Recovery can be transient and
after 5 minutes and if no clinical sometimes several doses may be
improvement required
9. If severe hypotension does not Improve hypotension
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 To assess whether episode is a
minutes after and no later than 6 genuine anaphylactic reaction
hours, for specific IgE antibody and
mast cell tryptase
12. Admit patient – at discretion of Repeat episode can occur 1 – 72
medical team hours after clinical recovery

Anaphylaxis Guidelines April 2010 7

Other Concurrent Measures

Action Rationale
If bronchospam severe and does not To reduce bronchospam
respond to other treatment –
administer Salbutamol

Provide support to the patient and To reduce patient anxiety and

their family. Display a calm, promote wellbeing, by educating
competent and confident disposition. patients on delayed side effects and
Reassure and explain to the patient how to deal with them in the first
and any relatives what is being done instance
and what should be expected to
happen shortly.

Ensure the episode is accurately To meet legal requirements and

documented (to include sensitivity) in prevent/minimise future problems
appropriate nursing and medical
records

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 3. IV Fluid Challenge:

adrenaline) IM doses of 1:1000 adrenaline (repeat
after 5 min if no better) Adult – 500 – 1000 mL
• Adult 500 micrograms IM (0.5 mL) Child – crystalloid 20 mL/kg
• Child > 12 years 500 micrograms IM (0.5 mL)
• Child 6 – 12 years 300 micrograms IM (0.3 mL) Stop IV colloid if this might
• Child < 6 years 150 micrograms IM (0.15 mL) 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
Anaphylaxis 6 months April 2010
Guidelines 250 micrograms/kg 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 Medical
Experienced Staff
Notified &
Present

Nursing Follow Up
Action 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