Primary Care practice clinics within the Edmonton Southside Primary Care Network.

Transcription

1 Allergy/Immunotherapy Injections Last Review: November 2016 Intervention(s) and/or Procedure: Administration of allergen injections throughout immunotherapy treatment. Immunotherapy for allergic disease involves subcutaneous administration of allergen(s) serums that the patient is sensitive to in order to decrease the immune response to the allergen and improve allergic symptoms, prevent progression of allergic disease, and prevent development of allergic asthma in children. Practice Setting: Authorized Implementers: Competencies and Educational Requirements: Indications/Clinical Conditions: Primary Care practice clinics within the Edmonton Southside Primary Care Network. Registered Nurses (RN) in the role of Primary Care Nurse (Edmonton Southside Primary Care Network). 1. The nurse must assess his/her individual competence in all aspects of the intervention and decide if it is appropriate for him/her to perform the procedure. 2. The nurse must engage in continuing professional development to achieve and maintain competence. 1. Verbal consent received from the patient for the implementing RN to implement this medical directive. 2. Patient has been prescribed specific allergen solution by a physician/specialist. 3. The allergen vial is accompanied by a current order describing dosage and interval as well as the vial to be used. 4. The patient must agree to remain onsite as indicated in the treatment order sheet with the immunotherapy vials. 5. In case of adverse reaction, emergency drugs and equipment must be available (see Appendix A).

2 6. A physician must be available onsite during the injection and for the specified monitoring time following the injection, each time the injection is provided. Contraindications and Exclusions: 1. Severe or very labile asthma is a relative contraindication due to risk for severe bronchospasm. 2. Patients on beta-blockers or angiotensinconverting enzyme (ACE) inhibitors. 3. No verbal consent from patient or substitute decision maker for RN to implement this medical directive. 4. Individuals who have a temperature over 38 degrees celcius or are feeling unwell. 5. Individuals who developed a severe reaction after the last injection consult the treatment order sheet provided by the prescribing physician to determine the appropriate course of action. 6. Individuals that have missed scheduled injections since last visit. Consult with treatment order sheet or with the ordering physician to determine appropriate dose of allergen to administer. Guidelines for Implementation (all above indications must be met): Assessment, Treatment, and 1. Ensure allergen vial has been kept refrigerated Monitoring Parameters: and stored correctly prior to the injection. 2. Collect history from patient chart and patient report on any previous reactions or delayed reaction to the most recent injection. 3. The allergen injection will be given SC to the upper arm according to the manufacturer's instructions and treatment order sheet included with the allergen vial. 4. The patient is asked to remain in the clinic following the injection to monitor for reaction for the amount of time specified in the treatment order sheet. 5. If at anytime a systemic reaction occurs NOTIFY THE PHYSICIAN IMMEDIATELY; HAVE EMERGENCY MEDICATIONS READY!

3 Communication and Documentation: 6. After specified observation time, patient is to be re-assessed by the RN before discharge. Check injection site for any reaction and assess patient for any signs or symptoms of a systemic reaction. 7. Consult treatment order sheet to determine appropraite course of action based on the extent of any local reaction (redness, swelling, warmth). 8. Discharge Instructions: a) To seek emergency medical care should a systemic reaction develop. b) To notify Physician or RN of any delayed reaction and the timeline and extent of the reaction at the next visit. 1. All information pertaining to the injection is documented on the treatment order sheet maintained with the allergen vial and/or in the patient record according to standard documentation practices.* (requisite information includes explanation of any prior reaction to the allergen, dosage, injection site, documentation of any immediate reaction.) 2. Documentation in the patient s medical record needs to include: name of the directive, name of the implementer (including credential), and name of the physician/authorizer responsible for the directive and patient. 3. Information regarding implementation of the procedure and the patient s response should be documented in accordance with standard documentation practice. * Implementation of Protocol in Practice Setting: 1. The Primary Care Nurse (RN) and the authorizing physician in each clinic must sign the Edmonton Southside Primary Care Network "Medical Directive and Protocol Approval Form" indicating acceptance of this medical directive for implementation in the primary care practice setting. 2. Upon accepting this medical directive, it is in permanent effect (including in the case of revisions to the protocol) until otherwise retracted. 3. The implementing RN within each clinic is responsible to notify the authorizing physician(s) of any updates to the medical directive/protocol. Endorsed by: Clinical Governance Committee Date: November 21, 2016

4 References: Creticos, P. S. (2015). Subcutaneous immunotherapy for allergic disease: Indications and efficacy. Retrieved from *Potter, P.A. & Perry, A.G. (2006). Fundamentals of Nursing. St. Louis: Mosby.

5 Appendix A Emergency Drug Kit Recommended Contents 1. Copy of anaphylaxis procedures and doses recommended of epinephrine and diphenhydramine for weight and age 2. Epinephrine (1:1000 concentration) x 2 vials 1 3. Diphenhydramine (50mg/mL) x 1 vial or oral solution/pills 4. Salbutamol (Ventolin) - via MDI inhaler or nebulizer 5. 1cc syringes with attached needles x 2 (1 x 25g, 5/8 needle, 1 x 25g, 1 needle) 6. 25g, 5/8 needle x g, 1 needle x 2 8. Alcohol swabs 1 An EpiPen administration kit can be used in place of Epinephrine vials. EpiPens are not recommended over Epinephrine vials, as Epinephrine is more cost effective and provides variable drug dosing options. Instructions should be followed on the product monograph.

6 Appendix B Guidelines for the Management of Anaphylaxis 2 Anaphylaxis is a medical emergency and rapid recognition and management can be life-saving. Every vaccine provider should be familiar with the signs and symptoms of anaphylaxis and be prepared to act quickly. Step 1 Assess circulation, airway, breathing, alertness/loc, and age. Establish an oral airway, if necessary. Step 2 Call for assistance and 911. Alert a physician in clinic of the anaphylaxis reaction. Step 3 Promptly administer Epinephrine by SC or IM injection (see table for recommended amounts) Epinephrine (1:1000) Age Dose (SC or IM) 0 6 mos * 0.01 mg/kg body weight (up to 9 kg) 7 18 mos 0.10 ml (0.10 mg) 18 mos 4 yrs 0.15 ml (0.15 mg) 5 yrs 0.20 ml (0.20 mg) 6 12 yrs 0.30 ml (0.30 mg) 13 yrs 0.50 ml (0.50 mg) *** By weight, dosage is generally 0.01 mg/kg. ADOLESCENT or ADULT: maximum mg CHILD: maximum mg For a mild reaction, a dose of 0.3 mg can be considered Step 4 Position patient on their back. Elevate the feet, if possible. a. If in respiratory distress: Place in a position of comfort. b. If vomiting or unconscious: Position the patient on their side. c. If pregnant: Use a semi-recumbent position on their left side with their legs elevated. Step 5 Step 6 Place patient in the recumbent position, elevating the feet if possible If able, administer oxygen to the patient with cyanosis, dyspnea. Monitor SpO2. 2 Adapted from: Canadian Immunization Guide: Part 2 Vaccine Safety. Early vaccine reactions including anaphylaxis (2013, June)

7 Step 7 If epinephrine was given SC, then an additional 0.3 ml SC can be given in moderate to severe cases. Epinephrine can be repeated 2 x at 5 minute intervals, if necessary, for a total of 3 doses. Step 8 Administer Diphenhydramine (Benadryl) either PO or IM (see table for recommended amounts) Step 9 Diphenhydramine (Benadryl) Age Dose (SC or IM) Amount (IM) Dose (PO or IM) < 2 yrs 0.25 ml (12.5 mg) 2-4 yrs 0.50 ml (25 mg) 5-11 yrs ml (25-50 mg) 12 yrs 1.0 ml (50 mg) Consider an inhaled short-acting β-agonist if there is a bronchospasm resistant to epinephrine (max. 10 puffs by MDI) Step 10 Step 11 Monitor vital signs and assess frequently Arrange for rapid transport to hospital, even in mild cases

8 Appendix C Differentiating Between Anaphylaxis vs. Other Conditions Anaphylaxis Symptoms - Itchy, urticarial rash (over 90% of cases) - Progressive, painless swelling about the face and mouth, which may be preceded by itchiness, tearing, nasal congestion or facial flushing - Respiratory symptoms, including sneezing, coughing, wheezing, laboured breathing and upper airway swelling (indicated by hoarseness and/or difficulty swallowing) possibly causing airway obstruction - Hypotension, which generally develops later in the reaction and can progress to cause shock and collapse - Nausea, vomiting and diarrhea Treatment: See Enclosed Steps Fainting Symptoms - Sudden pallor - Loss of Consciousness - Brief clonic seizure activity Treatment: Place patient in the recumbent position. Recovery occurs with a minute or two, but they may remain pale, diaphoretic and mildly hypotensive for several more minutes. Anxiety Symptoms - Fearful - Pale and diaphoretic - Hyperventilation and c/o lightheadedness - Dizziness and Numbness - Complaint of tingling of face & extremities Treatment: Give reassurance & re-breathing using a paper bag until symptoms subside