Guidelines for the Recognition and Treatment of Acute hypersensitivity reactions including anaphylactic shock in Adult Oncology & Haematology Patients Version Three Date of Publication: Version 1 - June 2005 Version 2 September 2007 Version 3 October 2011 Authors: Helen West Lead Cancer Nurse - UHCW NHS Trust Sam Neale Lead Chemotherapy Advanced Nurse Practitioner, UHCW NHS Trust Sue Robinson Lead Cancer Services Pharmacist, UHCW NHS Trust Name of responsible committee/individual: Arden Cancer Network Chemotherapy Cross-Cutting Group Target audience: Haematology & Oncology Practitioners Date of Ratification: 28 th vember 2011 Ratified by: Arden Cancer Network Executive Group Date for Review: vember 2013
Version History Version 3 October 2011 Resuscitation Council (UK) Emergency Treatment of Anaphylactic Reactions guidelines for Healthcare Providers (2008) reviewed and added to document. Version 2 Sept 2007 Additional point added 7.13 Resuscitation website reviewed no changes in practice since May 2005 Version 1 Sept 2005 BNF reviewed Version Three 2
Contents Section Page 1.0 Introduction 4 2.0 Purpose 4 3.0 Scope 4 4.0 General Principles 4 5.0 Consultation and Communication Process 7 6.0 Equality Impact Assessment 7 7.0 Review and Revision Arrangements including Version Control 7 8.0 Dissemination and Implementation 7 9.0 References 8 10.0 Document Circulation 98 Appendices Appendix A Appendix B Appendix C Anaphylaxis Algorithm 10 Equality Impact Assessment Tool 13 Plan for Dissemination of Procedural Documents 15 Version Three 3
1.0 Introduction This principles document was developed by the Arden Cancer Network Chemotherapy Group incorporating; Alexandra Hospital (part of Worcestershire Acute Hospitals NHS Trust), George Eliot Hospital NHS Trust, South Warwickshire NHS Foundation Trust and University Hospitals Coventry and Warwickshire NHS Trust (UHCW). The document supporting these principles is the Resuscitation Council (UK) Emergency Treatment of Anaphylactic Reactions. Guidelines for Healthcare Providers. January 2008. This document is published by the Resuscitation Council (UK) and forms the basis for guidance within this Network document. 2.0 Purpose: To clearly state the correct management for the treatment of patients experiencing an acute hypersensitivity reaction including anaphylactic shock reaction during the administration of any systemic anti cancer treatment used for the treatment of malignant conditions. 3.0 Scope: Any adult patient attending the Oncology / Haematology Departments receiving systemic anti cancer treatment Those patients undergoing a treatment regime with a high risk of anaphylaxis will be prescribed a pre-medication to be administered as per individual chemotherapy prescription. 4.0 General Principles. 4.1 Responsibilities: The Registered Nurse is responsible for initiating the anaphylactic procedure in the event of a patient experiencing an acute hypersensitivity or anaphylactic reaction. 4.2 Definitions: Acute hypersensitivity or anaphylactic reactions are those experienced by patients who are hypersensitive or allergic to the drug being administered. The reaction will usually start suddenly during administration or shortly afterwards. These reactions can occur on the first administration (e.g. Rituximab) or as a result of multiple exposure (e.g. Carboplatin). CPR Cardiopulmonary Resuscitation I.V. Intravenous UNTREATED ANAPHYLAXIS CAN BE FATAL. Version Three 4
4.3 Signs and Symptoms 4.3.1 Airway problems: o Airway swelling o Hoarse voice o Stridor 4.3.2 Breathing problems o Shortness of breath o Wheeze o Patient becoming tired o Confusion caused by Hypoxia o Cyanosis o Respiratory Arrest 4.3.3 Circulation Problems o Signs of shock-pale, clammy o Increased pulse rate o Hypotension o Feeling faint, dizzy, collapse o Decrease consciousness level or loss of consciousness. 4.3.4 Other o Myocardial Ischaemia and ECG changes o Cardiac Arrest 4.3.5 Skin and/or mucosal changes o Erythema o Patchy generalised red rash o Urticaria o Angioedema 4.4 Procedure Refer to Resuscitation Council (UK) Algorithm Appendix 1 te if profound shock commence CPR immediately Version Three 5
5.0 Consultation and Communication Process The consultation process involves dissemination of draft documents for comment to: the Arden Cancer Network Drugs and Therapeutics Committee, consultants haematologists, oncologists and haematology/oncology specialist nurses, ward managers and pharmacists at George Eliot Hospital, South Warwickshire NHS Foundation Trust, University Hospitals Coventry and Warwickshire and Worcestershire Acute Hospitals NHS Trust. 6.0 Equality Impact Assessment See Appendix B. 7.0 Review and Revision Arrangements including Version Control The Chair of the Arden Cancer Network Chemotherapy Group will nominate an individual to undertake a review of the guidance 3 months prior to the revision date. 8.0 Dissemination and Implementation Once documents are ratified, notification will be sent by email to the lead chemotherapy clinician, nurse and pharmacist for each Trust. It will be their responsibility to disseminate and implement the protocol locally. The final version of documents will be placed on the Arden Cancer Network intranet and each individual Trust s intranet via a designated lead for each Trust. Hard copies will not be circulated. It will be the responsibility of departmental managers to remove outdated copies and to ensure staff are aware of the new version. It is the responsibility of departmental managers to implement any identified training or support. (Appendix C). 8.0 References Current British National Formulary UHCW Cardio Pulmonary Resuscitation Policy Resuscitation Council (UK), The Emergency Medical Treatment of Anaphylactic Reactions for First Medical Responders and for Community Nurses. Revised May 2005 Resuscitaction Council (UK) Emergency Treatment of Anaphylactic Reactions. Guidelines for Healthcare Providers. January 2008 Version Three 6
9.0 Document Circulation Name Title Trust Dates Circulated Dr Jag Gandla Lead Chemotherapy Clinician George Eliot Hospitals NHS Elaine Watkins Lead Chemotherapy Nurse Trust Melanie Taylor* Lead Chemotherapy Pharmacist Stephanie Cooke Lead Aseptic Pharmacist Alexandra Hospital Part Fay Lanham Chemotherapy Unit Manager of Sue Sharp Chemotherapy/Radiot herapy Project Nurse Worcestershire Acute Hospitals Ann Sullivan Cancer services Manager/Macmillan NHS Trust Lead Cancer Nurse Dr Anton Borg Lead Chemotherapy Clinician South Warwickshire Carole Connor* Head of Chemotherapy NHS Foundation Nicola Turner Lead Chemotherapy Trust Dr Lydia Fresco Dr Beth Harrison** Dr Clive Irwin Sam Neale* Rebecca Aaron Stephanie Connell*** Pharmacist Lead Chemotherapy Clinician Chair of the Haematology Network Site Specific Group Chair of Arden Cancer Network Chemotherapy Group Lead Chemotherapy Nurse Chemotherapy Pharmacist Service Improvement Facilitator University Hospitals Coventry and Warwickshire NHS Trust Arden Cancer Network *Responsible for circulating to relevant staff within their Trust including clinical nurse specialists, oncologists and ward managers. **Responsible for circulating to Haematology Network Site Specific Group Members ***Responsible for circulating to Network Chemotherapy Cross Cutting Group Version Three 7
Anaphylaxis Algorithm Reuscitation Council (UK) 2008 Appendix A 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 patient s 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, SpO2 < 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) Adrenaline IV to be given only by experienced specialists Titrate: Adults 50 micrograms; 3. IV fluid challenge: Adult - 500 1000 ml Stop IV colloid if this might be the cause of anaphylaxis Version Three 8 4 Chlorphenamine 5 Hydrocortisone (IM or slow IV) (IM or slow IV) Adult or child more than 12 years 10 mg 200 mg
Appendix B - Equality Impact Assessment Tool 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? Yes/ 5. If so, can the impact be avoided? N/A 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? ne Comments Version Three 9
Appendix C - Plan for Dissemination of Procedural Documents Title of document: Guidelines for The Recognition and Treatment of Acute hypersensitivity reactions Date finalised: Previous document already being used? 28 th vember 2011 Yes Dissemination lead: Sam Neale Arden Cancer Network Lead Chemotherapy Nurse If yes, in what format and where? Guideline for the Management of Anaphylaxis in Oncology & Haematology Patients Proposed action to retrieve out of date copies of the document: Version 2 - Network Wide document across Haematology and Oncology. Chemotherapy lead nurse for each Trust to retrieve local documents. To be disseminated to: How will it be disseminated, who will do it and when? Format (i.e. paper or electronic) Comments: Stephanie Connell Arden Cancer Network Karen Pedley Lead Cancer Nurse George Eliot Hospitals NHS Trust Carole Connor Lead Chemotherapy Nurse South Warwickshire NHS Foundation Trust To inform all areas that revised network wide electronic version available on Trusts intranet and Arden Cancer network site with 7 days of receipt Electronic Sent by email Sam Neale Lead Chemotherapy Nurse University Hospitals Coventry and Warwickshire NHS Trust Dissemination Record - to be used once document is approved Date put on register / library of procedural documents: 28 th vember 2011 Date due to be reviewed: vember 2013 Disseminated to: (either directly or via meetings, etc.) Format (i.e. paper or electronic) Date Disseminated:. of Copies Sent: Contact Details / Comments: Directly Electronic 29 th vember 2011 One Sam Neale Arden Cancer Network Lead chemotherapy Nurse Version Three 10