Inflammation Anaphylactic Reaction Osborn

Pg 549 - Transfusion Reactions

Class
Allergic reaction

Cause
y Recipient s sensitivity to foreign plasma proteins y Common in patients with allergies

Clinical Manifestations
y Itching, hives, flushing, and chills y y y y

Nursing Care
Slow the transfusion Take vital signs Notify HCP May be necessary to medicate with antipyretics and/or antihistamine. Then resume the transfusion Stop transfusion, but maintain IV site Give antipyretics as prescribed Take vitals Notify HCP Obtain urine and blood sample Send blood bag, normal saline, and IV tubing to the laboratory Consider using leukocytepoor blood

Febrile Nonhemolytic Reaction

y Due to leukocyte or thrombolytic incompatibility (donor s WBCs or platelets react with recipient s antibodies) y Usually occurs after multiple transfusions y Accounts for 90% of transfusion reactions y Fever begins about 2 hours after the transfusion y WBC reduced blood helps prevent these reactions y May occur up to 14 days after a transfusion when the level of the antibodies has increased to the extent that a reaction occurs

y Increased pulse rate, temperature >1 C, chills, headache, n/v, anxiety, flushing, back pain, muscle aches.

y y y y y y

Delayed hemolytic reaction

y Fever, anemia, increased bilirubin level, decreased or absent haptoglobin, and jaundice

Acute hemolytic reaction

y ABO incompatibility of the blood and recipient y May be due to a mistake in labeling by laboratory or blood bank or nursing error y Causes agglutination of cells, which causes obstruction of the capillaries and blockage of

y Bloody urine and decreased urine output y Petechiae, jaundice, decreased BP, chest tightness, low back pain, nausea, anxiety and dyspnea. Hypotension, bronchospasm, and vascular collapse may occur.

y Generally not dangerous , but it is important to recognize the reaction because subsequent transfusions may cause a more severe hemolytic reaction y Typically not recognized or treated due to the mild nature of the reaction y Emergent life-threatening situation y stop transfusion, but maintain IV site and infuse IV colloid solutions to maintain BP y give diuretics as prescribed to maintain urine flow

blood flow

Hemogobinemia, acute renal failure, shock, cardiac arrest, death. y Symptoms typically occur within the first 15 minutes of the transfusion

Hemolytic or anaphylactic reaction

y reaction to donor plasma proteins y specifically, infusion of IgA proteins to an IgA-deficient recipient who has an IgA antibody

y wheezing, restlessness, anxiety; progressing to cyanosis, shock, and possibly cardiac arrest

y insert urinary catheter to assess output and color y vital signs y treat sock y start CPR if necessary y give epinephrine y notify HCP y obtain urine and blood sample y send blood bag, normal saline, and IV tubing to the lab y stop infusion but maintain IV site. Give epinephrine per doctor s orders. Initiate CPR if necessary y notify HCP y obtain urine and blood sample y Send blood bag, normal saline, and IV tubing to the lab.

Pg 980 Allergy Reactions and Treatments

Reaction Local reaction Symptoms y Erythema arm swelling of 2-3 cm, itchy eyes, slight body itching, transient local itching y Conjunctivitis, urticaria, chest tightness, problems breathing, syncope, wheezing, difficulty swallowing, SOB, dyspneic hives, decrease in blood pressure y y y y y y y y y y y Treatment Ice/elevation Observe closely until reaction resolves. Fill out anaphylaxis treatment record in patient s chart Maintain airway O2 at 5L/Min. Place venous tourniquet above injection site Check vital signs, peak flow, pulse oximetry every 5-10 minutes Start two (14-16) IV s bolus 250-500 mL NS Repeat PRN for BP stability Continue to check vital signs every 5 minutes until reaction is resolved Call 911 and transport to ED Fill out anaphylaxis treatment record in patient chart y y y Medications Antihistamines Steroids Claritin, Zyrtec, Benadryl

Systemic reaction, anaphylaxis

y y

y y y

1:1000 epinephrine up to 0.3-0.5 mL IM Chlorpheniramine 4 mg po or diphenhydramine 25-50 mg po or IM Albuterol 2.5 mp nebulizer or 8 puffs metered-dose inhaler if wheezing Prednisone 60 mg po or solu0medrol 125 mg IV Zantac 50 mg IV/Pepcid 20 mg IV Glucagon 1 mg (especially if on beta blockers)

Pg 1895-1896
Anaphylactic Reaction y Anaphylaxis can be localized or systemic hypersensitivity response to an antigen that can quickly progress to a medical emergency if not recognized and treated appropriately y Symptoms itching, erythema, vomiting, and breathing difficulties to severe laryngeal edema, respiratory distress, vascular collapse, shock and death. o Symptoms are usually immediate (less than 30 minutes), although the oral route allergen exposure can have a 2 hour delay. y Secondary response or biphasic reaction is seen in approximately 20% of patients with anaphylaxis and can occur 4-8 hours after the initial remission of symptoms due to secondary mediators of inflammation such as bradykinin. y The result of severe systemic anaphylactic reaction is a form of shock called distributive shock that results in massive vasodilatation, loss of blood pressure, and inadequate distribution of blood supply and oxygen to all tissues. y Concurrent smooth muscle bronchoconstriction and laryngeal edema initially cause inspriatory and expiratory wheezing and difficulty breathing, which may progress to complete airway obstruction. y Death can result from circulatory collapse or severe bronchial constriction, or a combination of both. Patients can be in extreme danger when breath sounds diminish after wheezing because the airways are completely constricted and no air is being inspired or expired due to edema. y Treatment focuses on immediate administration of IM adrenaline which reverses vasodilatation and decreases edema. It relaxes smooth muscle thus dilating bronchioles, suppresses histamine release, and increases myocardial contractility. Administration of supplemental O2, establishment of IV access, and administration of IV fluid to support IV volume in patients with hypotension Corticosteroids are key to control inflammation mediators Antihistamines and inotropic antiarrhythmic agents

y y y

Medical Management of Allergic Hypersensitivity Response y Treatment is focused on avoidance of triggering allergens, prevention of a hypersensitivity response, and relief of allergy symptoms. y Identifying causative factors is key. y For severe reactions, treatment may include allergy desensitization shots A thorough history of allergies is essential prior to the start of any medications. Individuals with a family history of hypersensitivity response are at greater risk for allergic response. The nurse must be aware of patient s allergies prior to administering any medication. This is especially crucial with IV medications, such as antibiotics, because the antigen is given directly into the bloodstream, bypassing the local response delay, and can result in stimulation of an immediate severe anaphylactic reaction. Laboratory & Diagnostic Procedures y Includes blood and sputum lab tests to determine total IgE and allergen-specific IgE & Skin tests with small amounts of allergens to evaluate sensitivity.

Blood Tests y To detect lymphocyte, eosinophils, and immunoglobulin abnormalities = CBC w/ Diff.  Provides a total lymphocyte and eosinophils count.  Eosinophils count is usually elevated with type 1 hypersensitivity reactions and is one of the indicators used to confirm a diagnosis of allergy. y Nasal smears, sputum, and bronchial secretions may also be tested for the presence of eosinophils, which indicate probable allergy y Radioimmunosorbent test (RIST)  Measures circulating levels of total IgE y Radioallergosorbent test (RAST)  Provides sensitive measurement of the specific IgE antibodies that are elevated in response to many allergens Skin Tests y Introducing small amounts of various allergens into the skin of allergic individuals through either intradermal injection or a scratch or prick test , technique on the patient s back o Prick tests is least sensitive of the two tests but also carries a lower risk of systemic reaction. y Allergy meds including antihistamines and corticosteroids are generally held 48-96 hours prior to testing.

Pg 1899-1903 Care Plans. Refer to text Pg 1957 shock symptoms and Causes of Specific Shock Symptoms
Shock Syndrome Anaphylactic shock Cardiogenic shock Causes Insect bites, medication allergies, food allergies, latex allergies, idiopathic reactions Myocardial infarction, myocardial contusion Ruptured ventricles Ruptured papillary muscles cariomyopathy Traumatic injury (Abdominal trauma, chest trauma, orthopedic trauma), GI bleeding, vomiting, diarrhea, osmotic diuresis, diabetic ketoacidosis, thermal injuries Spinal cord or medulla trauma, anesthetic agents, severe emotional stress, severe pain Bacterial infections, viral infections, immunosuppression, technology (indwelling catheter or IV catheter, feeding tube), Antibiotic use. Etiology Major loss of blood or circulating body fluid such as plasma Injury or toxin affects the blood vessels, which results in the redistribution of blood and fluid. Ie: in spinal shock, damage to the sympathetic nervous system causes vasodilatation and alteration in blood distribution A condition that slows or obstructs blood flow in or out of the heart. Ie: cardiac tamponade, tension Pneumothorax, vena cava obstruction

Hypovolemic shock

Neurogenic Shock Septic Shock

Shock Syndrome Low-Volume Shock (absolute hypovolemia) High-Space Shock (relative hypovolemia)

Mechanical (obstructive) shock

London
Pg 920-921
Food Reactions & Nursing Management y Any adverse reaction to foods or substances ingested in foods y Food intolerance - Any abnormal physiological response to a food that is not IgE-mediated. o most common food reaction o Ie: indigestion or flatulence upon eating certain foods, a sweating reaction to some spices, rhinitis, and hives with urticaria. o Milk and grain products are common causes o Chemical additives, antibiotics, preservatives, and food colorings also can cause food sensitivity reactions y Food allergy IgE mediated reaction that is potentially systemic, characteristically rapid in onset, and may be manifested as swelling of the lips, mouth, uvula, and glottis, generalized urticaria, and in severe reactions, anaphylaxis. o most serious type of food reaction o most common cause of anaphylaxis & most prevalent in children with a family history of allergic reactions to various substances and most common food reaction (Atopy) o Most common cause fish, shellfish, peanuts, tree nuts, eggs, soy, wheat, corn, strawberries, and cow s milk products. y Children who have both food allergy and asthma are most at risk of death from anaphylaxis due to a food allergy y Awareness of hidden substances in prepared foods o Ie: people with nut allergies will experience a reaction to the food if nut extracts are used in its preparation. y Certain foods can cause either allergy or intolerance so accurate diagnosis is needed. o Ie: cow s milk that can cause an allergy with IgG mediated systemic reaction, or intolerance from a GI response to milk proteins (diarrhea, vomiting, abdominal pain) as a result of lack of the enzyme lactase in the GI tract. y Delayed hypersensitivity reactions are attributed to digestive products of food and require a thorough diet history of several days to ID the offending food. o More difficult to diagnose o Reaction can occur up to 24 hours after ingestion of the food. o Biphasic reactions that occur 1 to 30 hours after an initial anaphylaxis. o Promptly treated with epinephrine and transported to ED. y Diagnostic tests to ID suspected food allergies o Measurement of serum IgE levels o Scratch tests o Radioallergosorbent tests (RAST) radioimmunoassay measures IgE antibodies to specific allergens. y Diet diary o Date o Type of foods eaten o Reaction Nursing management y PREVENTION!!! y Instruct parents of infants to introduce new foods at a rate of not more than one new food every 5 days.

y y y y

Symptoms will disappear when the causative food is removed from the diet. Emphasize the importance of reading food labels Medical alert bracelet. Carry an Epipen

Pg 1209 Vaccine Anaphylaxis

y y y Be prepared when administering vaccines. Keep epinephrine and resuscitation equipment immediately available Dosage for epinephrine (aqueous 1:1000) is 0.01 mL/kg pe dose up to 0.5 mL IM o The dose can be repeated every 10 to 20 minutes for up to a total of 3 doses until symptoms subside or other emergency care is available

Pg 1431-1432
Allergic Reactions y Allergy is an abnormal or altered reaction to an antigen, allergen. y Allergens can be ingested in food or drugs, injected or absorbed through contact with unbroken skin, and inhaled. y Common allergens o Medications (ie: penicillin) o Animal dander o Dust, mites, and mold o Plant pollens o Foods (ie: nuts, seafood, egg white) y An allergic reaction is an antigen-antibody reaction and can manifest itself as anaphylaxis, atopic disease, serum sickness, or contact dermatitis. y Therefore the symptoms can be mild to severe or life threatening and they can be localized or systemic. y Hypersensitivity response is an overreaction of the immune system & is responsible for allergic reaction. o Type 1 hypersensitivity reactions are immediate (seconds to minutes of exposure). The release of chemical substances such as histamine is responsible for the signs and symptoms. The first time a child is exposed to the allergen, there is no reaction. With every exposure thereafter, the allergic child may have a reaction to the allergen. o Type 2 sensitivity reactions occur within 15-30 minutes after exposure. o Type 3 sensitivity reaction may be difficult to distinguish from type 2. Hypersensitivity reactions generally peak within 6 hours. o Type 4 sensitivity reactions are delayed responses that do not appear until several hours after exposure and require 24 to 72 hours to fully develop. It is not confined to any specific tissue and is elicited by relatively complex antigens such as those of bacteria and viruses and by simple antigens such as drugs and metals y Page 1431 characteristic findings in children with allergies y Page 1432 types of hypersensitivity reactions