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Nurses can follow 'subtle signs' to prevent infusion reactions
FORT WORTH, Texas — Rheumatology nurses who serve patients in infusion centers can help prevent reactions by being aware of “subtle signs,” such as a slight cough or restlessness, that indicate a coming infusion reaction, according to Vickie L. Sayles, BSN, CRNI, RN-BC, of the Cleveland Clinic Foundation.
“When the infusion begins, and suddenly you hear throat clearing, slight coughing and the patient becoming restless, I will send the nurse over there immediately, because that is the first indication that they are going to react,” Sayles, who manages the Cleveland Clinic’s infusion room, told attendees at the Rheumatology Nurses Society Annual Conference. “Often the patient will not even realize they are beginning to react, and will just ask for a glass of water.”
Sayles added that nurses assessing a patient for a possible infusion reaction should look for scratchy throat, itchy ears or nose, a feeling of a “pebble” in the throat when swallowing, nasal congestion, itching or rash. If any of these symptoms are present, even to a mild degree, the nurse should cease the infusion immediately and administer 50 ml to 100 ml per hour of saline.
According to Sayles, the Cleveland Clinic’s infusion room hypersensitivity orders are to start with 50 mg of IV diphenhydramine. Once the reaction symptoms have completely resolved, staff can restart the premedication process.
However, if the reaction persists after 15 to 20 minutes, the patient is given 60 mg of IV solumedrol, and if there are any symptoms present after waiting another 15 to 20 minutes, nurses will contact the provider for instructions. Epinephrine is typically reserved for instances of anaphylaxis, she said.
If reaction symptoms appear to worsen after the first dose of diphenhydramine, nurses should seek advice or call the medical emergency response team if warranted, Sayles said, adding that the persistence of even mild symptoms following diphenhydramine and the steroid could indicate a more severe reaction is pending.
According to Sayles, nurses can help prevent such infusion emergencies by following these steps:
- When restarting the premedication process, wait a full 20 minutes before re-administering rituximab (Rituxan, Genentech) after administering the steroid;
- Pay attention to subtle signs, including scratchy throat, itchy ears or nose, slight coughing and restlessness;
- Realize that the patient may downplay or minimize reaction symptoms;
- Never be in a hurry to restart the medication after reaction symptoms occur; and
- Track the patient’s reaction symptoms to determine if there is a pattern of behavior.
Sayles added: “That includes time into infusion, the drug being administered, pre-medications and the patient’s disease state.” – by Jason Laday
Reference:
Sayles SL. The infusion rheum. Presented at: Rheumatology Nurses Society Annual Conference; Aug. 8-11, 2018; Fort Worth, Texas.
Disclosure: Sayles reports speaking fees from Kevzara and Sanofi Genzyme.