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Course: Oncology Nursing

Topic: Nursing Management of

Oncological Emergency - Anaphylaxis

The Nurses International Community

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Module Goals

Learners will be able to:

Explain the underlying pathophysiology of Anaphylaxis.
Describe the scope of the problem including the incidence, etiology and risk factors for this oncologic emergency.
List the clinical manifestations that are associated with this emergency situation.
Explain the nursing assessment for Anaphylaxis including relevant diagnostic tests.
Characterize the nursing interventions and supportive care important to address this problem in a timely and effective manner.

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Definition

“Anaphylaxis is a severe, systemic hypersensitivity reaction that is rapid in onset and characterized by life-threatening airway, breathing, and/or circulatory problems, and that is usually associated with skin and mucosal changes.”

The recent “International Consensus on (ICON) Anaphylaxis” described anaphylaxis as “a serious, generalized or systemic, allergic or hypersensitivity reaction that can be life-threatening or fatal”

Reber, Hernandez, & Galli, 2017

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Causes

Delves, 2020

Common causes of anaphylaxis include:

Foods
Medications
Insect stings
Latex

First exposure to a foreign substance does not cause an anaphylactic reaction, but subsequent exposure can cause anaphylaxis.

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Causes of Anaphylaxis in Cancer

Allergic reactions can occur after taking almost any drug
Chemotherapy drugs that have been reported to cause a systemic allergic reaction in more than 10% of patients include:

Melphalan
Procarbazine
Asparaginase —occurs in more than 30% of patients
Pegaspargase —occurs in more than 30% of patients

Virginia Cancer Institute, 2021

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Case Study/Critical Thinking Question/What would the nurse do?

Miss Anna is a 25 year old female patient who developed an anaphylactic reaction noted by rashes, dyspnea and abdominal pain. What would the nurse consider as possible causes? (Select all that apply)

Foods
Medications
Latex products
Insect stings

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Risk Factors for Anaphylaxis in Cancer

Infusion reaction of a specific drug
Age-related factors
Other issues including chronic respiratory and cardiovascular diseases
Mastocytosis or clonal mast cell disorders
Severe atopic disease
Some concurrent medications such as β-adrenergic blockers and angiotensin-converting enzyme inhibitors might also increase the risk

Rosello et al., 2017

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Pathophysiology

Delves, 2020

Triggers release of histamine, leukotrienes, and other mediators

Bronchoconstriction,vomiting, vasodilation

Diffuse smooth muscle contraction

Interaction of antigen with IgE on basophils and mast cells

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Mechanisms of an allergic reaction

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Pathophysiology

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Pathophysiology

Reber, Hernandez & Galli, 2017

Effector molecules:

1. IgE:

On exposure of allergen:

IgE induces activation of mast cells and basophils that release histamine and various proteases, as well as de novo synthesis of many inflammatory mediators such as certain leukotrienes, prostaglandins, and cytokines.

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Pathophysiology

Effector molecules:

2. IgG: also can induce passive systemic anaphylaxis (PSA) reactions, with physiological manifestations similar to those seen in IgE.

3. Role of complement: Activation of the complement cascade occurs in response to many stimuli, and leads to generation of small polypeptides: C3a, C4a and C5a,

Also known as anaphylatoxin.which are potent inflammatory mediators.

Reber, Hernandez & Galli, 2017

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Pathophysiology

Potential effector cells of anaphylaxis:

Mast Cells:

Are viewed as key players in IgE-dependent allergies and anaphylaxis
Secretion of several biologically active products such as histamine and various cysteinyl leukotrienes (Cys-LTs).

Basophils:

Basophils participate in anaphylaxis.
For example, IgE-dependent activation of human basophils is associated with elevations in the levels of certain basophil cell surface markers, such as CD203c or CD63,

Reber, Hernandez & Galli, 2017

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Pathophysiology

Potential effector cells of anaphylaxis:

Monocytes:

Express high levels of activating FcγRs, and can also respond to anaphylatoxins.

Neutrophil:

Express several activating FcγRs, produce histamine, and release platelet-activating factor (PAF) in response to stimulation with immune complexes.

Platelets:

Anaphylaxis in humans is associated with platelet activation, and activated platelets can release mediators, such as platelet factor 4 (PF4) and serotonin, which might contribute to the pathophysiology of anaphylaxis.

Reber, Hernandez & Galli, 2017

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Pathophysiology

Potential mediators of anaphylaxis:

Histamine: Important mediator of anaphylaxis.
Platelet Activating factors (PAF):

PAF is a potent phospholipid-derived mediator implicated in platelet aggregation and thought to play important roles in a variety of immune and inflammatory responses.

Cysteinyl leukotrienes (CysLTs):

Synthesized from arachidonic acid by a variety of cells, including mast cells, basophils and macrophages.

Other potential mediators: Includes tryptase, prostaglandins, and cytokines/chemokines.

Reber, Hernandez & Galli, 2017

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Symptoms of Anaphylaxis

Virginia Cancer Institute, 2021

Difficulty breathing
Faintness and lightheadedness (due to very low blood pressure)
Rapid heart rate
Swelling : tongue, lips, or mouth
Nausea, vomiting
Abdominal pain

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Anaphylaxis Symptoms

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Clinical Criteria for Diagnosis of Anaphylaxis

1. Acute onset of an illness with involvement of skin/mucous membranes and at least one of the following:

Respiratory compromise (e.g. dyspnoea, bronchospasm, stridor, reduced peak expiratory flow, hypoxaemia)
Reduced blood pressure or associated symptoms of end-organ dysfunction [e.g. collapse, syncope, incontinence]

Rosello, et al., 2017

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Clinical Criteria for Diagnosis of Anaphylaxis (continued)

2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):

Involvement of skin/mucous membranes
Respiratory compromise (e.g. dyspnoea,hypoxaemia)
Reduced blood pressure
Persistent gastrointestinal symptoms (e.g. crampy abdominal pain, vomiting)

3. Reduced blood pressure after exposure to a known allergen (minutes to several hours):

Adults: systolic blood pressure of < 90 mmHg or > 30% decrease from that person’s baseline

Rosello et al., 2017

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Case Study/Critical Thinking Question/What would the nurse do?

What Symptoms of anaphylaxis might a patient experience following a medication? (Select all that apply)

Skin rash
Difficulty in breathing
Vomiting
Abdominal pain

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Diagnostic Approach to Anaphylaxis

1. Historical Information:

Any potential allergen exposure (timing/duration of exposure)
Presence of any cutaneous manifestations
Any signs of airway obstruction (upper/lower airway)
Any syncope or presyncopal symptoms
Presence of gastrointestinal symptoms
Any treatment given prior to presentation
Recurrence of symptoms after remission
Prior history of anaphylaxis

Abuali, I., 2017

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Diagnostic Approach to Anaphylaxis

1. Historical Information:

Identifying patients that are at higher risk for anaphylaxis:

Teenagers/young adults are risk for food allergen
Patients with asthma and/or cardiovascular disease a
Elderly patients are at increased risk due to other comorbidities
Certain medications (e.g. beta-blockers, antihistamines)

Abuali, I., 2017

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Diagnostic Approach to Anaphylaxis

2. Physical Examination:

Anaphylaxis may affect two or more of five major organ systems:

Skin (flushing, urticaria, pruritus)
Pulmonary (Dyspnea, wheezing, congestion, stridor)
Gastrointestinal ( Nausea, Vomiting, abdominal pain)
Cardiovascular (Tachycardia/Bradycardia, hypotension, syncope)
Neurogenic (Headache, Confusion, irritability, dizziness)

Pulmonary and cutaneous manifestations are the most common

Abuali, I., 2017

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Diagnostic Approach to Anaphylaxis

2. Laboratory, radiographic and other tests:

Plasma histamine level (sample should be obtained within one hour)
Complete blood count (CBC),
Cardiac enzymes (creatine kinase (CK), troponin)
Chest x-ray (evaluate for stridor, pneumothorax)
Computed tomography (rule out pulmonary embolism (PE))
Electrocardiogram (ECG) (rule out myocardial infarction (MI)

Abuali, I., 2017

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Management of Anaphylaxis

Preparation:

Before the administration of any drug, the patient should be asked about medical history, previous allergic disorders, atopic status and concomitant treatments
If premedications are to be taken orally, oncology nurses should check that the patient has actually taken them
An updated protocol for the management should be in hand

Rosello, et al., 2017

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Management of Infusion Reactions

ESMO Clinical Practice Guidelines S. Roselló, Jordan, 2017

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Nursing Intervention

History taking
Assess for signs and symptoms of anaphylaxis
Stop the administration of medication if Infusion reaction
Assess Airway, Breathing, Circulation
Monitor Oxygen, Oxygen therapy if needed
Maintain IV access
Medication:

Example: Epinephrine , Antihistamin, Corticosteroid.

The recommended dose of Epinephrine for adults is 0.3-0.5 mg per single dose IM at mid thigh

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Nursing Intervention

Position:

In the case of hypotension:

Place the patient in the Trendelenburg position

In the case of respiratory distress:

the patient should be sitting up; and,
if unconscious, the patient should be placed in a recovery position

Call for medical assistance as soon as possible
Continuous monitoring of patient

Rosello et al., 2017

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Case Study/Critical Thinking Question/What would the nurse do?

Miss Sharma is a nurse in an Oncology unit. She is starting chemotherapy on a 50 yrs male patient. 15 minutes after starting the chemo drug through Intravenous infusion, the patient had dyspnea and rashe over his face and all body parts. What action should the nurse take in this case? (Select all that apply).

Stop the infusion
Assess Airway, Breathing and Circulation
Give Oxygen
Administer injection Epinephrine IM

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Red Flag

Difficulty breathing
Low blood pressure
Rapid heart rate
Swelling : tongue, lips, or mouth
Nausea, vomiting
Abdominal pain

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References

Inas Abuali, 2021. Cancer Therapy Advisor: Anaphylaxis. Retrieved from https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/hospital-medicine/anaphylaxis-

Peter J. Delves,2020. MSD Manual : Anaphylaxis. Retrieved from https://www.msdmanuals.com/professional/immunology-allergic-disorders/allergic,-autoimmune,-and-other-hypersensitivity-disorders/anaphylaxis

Rosello, S., Blasco, I., Garcia, L. Cervantes, A., Jordan, K., 2017. Management of infusion reactions to systemic anticancer therapy: ESMO Clinical Practice Guidelines. SUPPORTIVE AND PALLIATIVE CARE| VOLUME 28, SUPPLEMENT . Retrieved from https://www.annalsofoncology.org/article/S0923-7534(19)42146-7/fulltext

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References

Reber, L. L., Hernandez, J. D., & Galli, S. J., 2017. The pathophysiology of anaphylaxis. The Journal of allergy and clinical immunology, 140(2), 335–348. https://doi.org/10.1016/j.jaci.2017.06.003

Virginia Cancer Institute, 2021. Allergic Reaction. Retrieved from https://www.vacancer.com/diagnosis-and-treatment/side-effects-of-cancer/allergic-reaction/

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