By Joe DiStefano, RPh.
Regardless of past tolerance to immune globulin (IG), a patient can have a reaction to any dose. Taking prescribed pre-medications and taking oral ones approximately 30 – 60 minutes before IG can help minimize or eliminate common adverse reaction such as headache and flu-like symptoms. While uncommon but serious, an anaphylaxis reaction can also occur and is the reason to always have the anaphylaxis kit readily available for use.
NuFACTOR recommends pre-medicating with acetaminophen and diphenhydramine and repeating if necessary during the infusion. Ultimately the physician decides whether or not to order pre-medications. NuFACTOR, however, requires physician orders for anaphylaxis for all IG patients. The orders describe specific symptoms and drugs to administer and are included on an information sheet within the anaphylaxis kit as well as in the New Patient Packet provided at start of care. Because of the route of IG administration, the subcutaneously IG (SCIG) kit does not contain parenteral diphenhydramine and IV normal saline.
Mild reactions include itching, rash and nausea with or without vomiting. If this occurs, stop the infusion and administer ordered dose of oral diphenhydramine.
Severe reactions include angioedema, wheezing, difficulty breathing and swelling of the eyelids and lips. If this occurs:
- Administer ordered dose of epinephrine.
- Stop the infusion.
- Call or have a caregiver call 911.
- Tilt patient’s head or thrust jaw to relieve airway obstruction if patient has problem breathing.
- For reaction to IVIG, administer ordered dose of parenteral diphenhydramine. For reaction to SCIG and if able to swallow, administer ordered dose of oral diphenhydramine.
- Monitor the patient’s vital signs. If hypotensive, elevate the patient’s legs.
- For reaction to IVIG, maintain the IV line with normal saline at keep vein open rate.
- If cardiopulmonary arrest occurs, begin CPR.
- Remain with patient until paramedics arrive.
- Arrange for rapid transport to an emergency department. Since 20% of anaphylaxis episodes follow a biphasic course with recurrence of the reaction after a 2 - 9 hour asymptomatic period, hospitalization or a long period of observation is recommended for monitoring.
- As soon as possible, inform the physician.
- Call NuFACTOR at (800) 323-6832 as soon as reasonably possible to report the reaction and reorder anaphylaxis kit medications.
Anaphylaxis orders are prescribed for specific drugs and symptoms. It is important for the Nurse to recognize anaphylaxis symptoms, know the steps to take and which kit medications to administer. The kit should not be used to treat other symptoms such as administering normal saline for headache. If your patient experiences other symptoms, contact the NuFACTOR pharmacist.