allergy immunotherapy in the college health setting new york state college health association 2010...
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Allergy Immunotherapy in the College Health SettingAllergy Immunotherapy in the College Health Setting
New York State College Health Association 2010 ANNUAL MEETING
Mary Madsen RN – BCAssistant Director, Clinical OperationsUniversity Health ServiceUniversity of Rochester
New York State College Health Association 2010 ANNUAL MEETING
Mary Madsen RN – BCAssistant Director, Clinical OperationsUniversity Health ServiceUniversity of Rochester
Allergies: immune system overreacts by producing antibodies called Immunglobulin E (IGE) these travel to cells and release chemicals, causing the
allergic reactions
Allergies: immune system overreacts by producing antibodies called Immunglobulin E (IGE) these travel to cells and release chemicals, causing the
allergic reactions
Allergy shots (immunotherapy) are aimed at increasing your tolerance to allergens that trigger your symptoms
Allergy shots work like a vaccine, your body responds to the increased injected amounts of a particular antigen and develops a resistance and tolerance
Indicated for allergic asthma, allergic rhinitis/conjunctivitis, stinging insect allergy
Allergy shots (immunotherapy) are aimed at increasing your tolerance to allergens that trigger your symptoms
Allergy shots work like a vaccine, your body responds to the increased injected amounts of a particular antigen and develops a resistance and tolerance
Indicated for allergic asthma, allergic rhinitis/conjunctivitis, stinging insect allergy
The preferred location for administration is the prescribing physician’s office, especially for high risk patients
AIT must be initiated and monitored by an allergist Pts. may receive AIT at another health care facility if the
physician and the staff are equipped to recognize and manage systemic reactions
Full, clear, detailed immunotherapy schedule must be present
Constant, uniform labeling system for extracts, dilutions and vials
Procedures to avoid clerical/nursing errors (i.e. pt. photo ID) (file by DOB)
The preferred location for administration is the prescribing physician’s office, especially for high risk patients
AIT must be initiated and monitored by an allergist Pts. may receive AIT at another health care facility if the
physician and the staff are equipped to recognize and manage systemic reactions
Full, clear, detailed immunotherapy schedule must be present
Constant, uniform labeling system for extracts, dilutions and vials
Procedures to avoid clerical/nursing errors (i.e. pt. photo ID) (file by DOB)
Issues in College Health SettingIssues in College Health Setting
Information needed from allergist Policies and procedures that increase safety Immediate and delayed reactions Recognition and treatment of anaphylaxis Preparedness plan for educating staff
Information needed from allergist Policies and procedures that increase safety Immediate and delayed reactions Recognition and treatment of anaphylaxis Preparedness plan for educating staff
Immunotherapy SafetyImmunotherapy Safety
Incidence of fatalities has not changed much in the last 30 years in the US
From 1990-2001 fatal reactions occurred at a rate of 1 per 2.5 million injections
Most occur during maintenance phase or “rush” schedule
Poorly controlled asthmatics at greatest risk Many deaths associated with a delay in
administering epinephrine or not giving it at all
Incidence of fatalities has not changed much in the last 30 years in the US
From 1990-2001 fatal reactions occurred at a rate of 1 per 2.5 million injections
Most occur during maintenance phase or “rush” schedule
Poorly controlled asthmatics at greatest risk Many deaths associated with a delay in
administering epinephrine or not giving it at all
Preparedness of health servicePreparedness of health service
Established medical protocols and treatment records
Stock and maintain equipment/supplies Physicians and staff maintain “clinical
proficiency” in anaphylaxis recognition and management
Consideration of drills tailored to assess skills, response, and preparedness of office staff
Tailor drill to consider access to local EMS- response times vary by location
Established medical protocols and treatment records
Stock and maintain equipment/supplies Physicians and staff maintain “clinical
proficiency” in anaphylaxis recognition and management
Consideration of drills tailored to assess skills, response, and preparedness of office staff
Tailor drill to consider access to local EMS- response times vary by location
Patient ResponsibilityPatient Responsibility
Patient must wait 20-30 minutes in office Those with prior systemic or delayed
reactions should wait longer Compliance with injection schedule Report any reactions to PCP and allergist Epi-Pen kits for self treatment
Patient must wait 20-30 minutes in office Those with prior systemic or delayed
reactions should wait longer Compliance with injection schedule Report any reactions to PCP and allergist Epi-Pen kits for self treatment
Local Reactions Are CommonLocal Reactions Are Common
Redness, swelling, warmth at site
Large, local, delayed reactions do not predict the development of severe systemic reactions
Local reactions may affect dosing schedule
Redness, swelling, warmth at site
Large, local, delayed reactions do not predict the development of severe systemic reactions
Local reactions may affect dosing schedule
Measurement Scales Differ between
allergist Measure in mm Compare to coin Grade 1+ - 4+ Length of reaction
Measurement Scales Differ between
allergist Measure in mm Compare to coin Grade 1+ - 4+ Length of reaction
Options for treating local reaction Options for treating local reaction
Don’t need MD order Change needle Ice to site Hydrocortisone to site Benedryl spray to site
Don’t need MD order Change needle Ice to site Hydrocortisone to site Benedryl spray to site
Do need MD order Non sedating
antihistamine prior to injection
Benedryl rinse Epi rinse Lowering dose Halt dose increase during
pollen season
Do need MD order Non sedating
antihistamine prior to injection
Benedryl rinse Epi rinse Lowering dose Halt dose increase during
pollen season
Benadryl or Epi Rinse InstructionsBenadryl or Epi Rinse Instructions
Draw Benadryl into syringe Pull plunger of syringe back until the entire barrel of syringe has been coated with
Benadryl Return Benadryl to original Benadryl
container Fill syringe with appropriate dose
Draw Benadryl into syringe Pull plunger of syringe back until the entire barrel of syringe has been coated with
Benadryl Return Benadryl to original Benadryl
container Fill syringe with appropriate dose
Systemic ReactionsSystemic Reactions
Incidence of systemic reactions ranges from 0.05% to 3.2% of injection
Most occur during maintenance phase Poorly controlled asthmatics at greatest risk Many deaths are associated with a delay in administering epinephrine
or not giving at all Risk factors include:
Dosing errors Symptomatic asthma High degree of allergy hypersensitivity Use of beta blockers/ACE-I New vials Injections during the allergy season Dosing protocols (rush regimens)
Incidence of systemic reactions ranges from 0.05% to 3.2% of injection
Most occur during maintenance phase Poorly controlled asthmatics at greatest risk Many deaths are associated with a delay in administering epinephrine
or not giving at all Risk factors include:
Dosing errors Symptomatic asthma High degree of allergy hypersensitivity Use of beta blockers/ACE-I New vials Injections during the allergy season Dosing protocols (rush regimens)
Symptoms of Systemic ReactionsSymptoms of Systemic Reactions
Any allergic symptom that occurs at a location other than the site of the injection
Chest congestion or wheezing Angioedema-swelling of lips,tongue, nose, or throat Urticaria, itching, rash at any other site Abdominal cramping, nausea, vomiting Light-headedness, headache Feeling of impending doom, decrease in level of
consciousness
Any allergic symptom that occurs at a location other than the site of the injection
Chest congestion or wheezing Angioedema-swelling of lips,tongue, nose, or throat Urticaria, itching, rash at any other site Abdominal cramping, nausea, vomiting Light-headedness, headache Feeling of impending doom, decrease in level of
consciousness
Anaphylaxis: potentially deadly allergic reaction that is rapid in onset, most commonly triggered by
food, medication or insect sting
Anaphylaxis: potentially deadly allergic reaction that is rapid in onset, most commonly triggered by
food, medication or insect sting Most common:ATB (penicillin, cephalosorins)
Food (nuts, cows milk, seafood) Insect
Age trends: Adolescents/young adults: foods Middle age: venom Older adults: medications
Most common:ATB (penicillin, cephalosorins) Food (nuts, cows milk, seafood)
Insect
Age trends: Adolescents/young adults: foods Middle age: venom Older adults: medications
Recognition of Anaphylaxisfor college health, this isn’t just for allergy injections!
Recognition of Anaphylaxisfor college health, this isn’t just for allergy injections!
Most reactions (1/2 – 1/3) occur in 20-30 minutes of vaccine 10% 30 – 60 min (asthma with multiple injections
Medication 10-20 min
Insect sting 10-15 min
Foods 25 – 35 min
Late phase (8-12 hrs) reactions possible Prompt recognition of potentially life threatening
reactions by staff and patients Urticaria/angioedema are the most common initial
symptoms--but they may be absent or delayed
Most reactions (1/2 – 1/3) occur in 20-30 minutes of vaccine 10% 30 – 60 min (asthma with multiple injections
Medication 10-20 min
Insect sting 10-15 min
Foods 25 – 35 min
Late phase (8-12 hrs) reactions possible Prompt recognition of potentially life threatening
reactions by staff and patients Urticaria/angioedema are the most common initial
symptoms--but they may be absent or delayed
Most Common Signs and SymptomsMost Common Signs and Symptoms
Skin: flushing, itching, urticaria: 90% Upper and lower airway signs: cough,
wheezing, dyspnea, change in voice quality, feeling of throat closing: 70%
GI symptoms: nausea, vomiting, diarrhea, crampy abdominal pain: 40%
Skin: flushing, itching, urticaria: 90% Upper and lower airway signs: cough,
wheezing, dyspnea, change in voice quality, feeling of throat closing: 70%
GI symptoms: nausea, vomiting, diarrhea, crampy abdominal pain: 40%
5 Most Common Factors in Fatal Reactions
5 Most Common Factors in Fatal Reactions
Uncontrolled asthma (62%) Prior history of systemic reaction (53) Injections during peak pollen season (43%) Delay/failure in epi treatment (43%) Allergy injection given IM instead of SQ or
dosing error (17%)
Also: upright posture
Uncontrolled asthma (62%) Prior history of systemic reaction (53) Injections during peak pollen season (43%) Delay/failure in epi treatment (43%) Allergy injection given IM instead of SQ or
dosing error (17%)
Also: upright posture
Recommended EquipmentRecommended Equipment
Stethoscope, BP cuff Tourniquet, large bore
IV needles, IV set-up Aqueous epinephrine
1:1000 O2 and mask/nasal
cannula Oral airway Treatment log
Stethoscope, BP cuff Tourniquet, large bore
IV needles, IV set-up Aqueous epinephrine
1:1000 O2 and mask/nasal
cannula Oral airway Treatment log
Diphenhydramine (oral and injection)
Albuterol nebulized Glucagon
Diphenhydramine (oral and injection)
Albuterol nebulized Glucagon
Immediate InterventionImmediate Intervention
Assess ABC’s Administer epinephrine ASAP! There is no
contraindication Fatalities usually result from delayed
administration of epinephrine--with respiratory, and cardiovascular complications
Subsequent care based on response to epinephrine
Assess ABC’s Administer epinephrine ASAP! There is no
contraindication Fatalities usually result from delayed
administration of epinephrine--with respiratory, and cardiovascular complications
Subsequent care based on response to epinephrine
EpinephrineEpinephrine
1:1000 dilution, 0.3 mg. dose administered IM or SQ q5 minutes as needed to control BP and other symptoms Tourniquet above injection site Pt can use their Epi-pen
Effect of epi can be blunted by beta-blockers, with severe, prolonged sx including bronchospasm, bradycardia, and hypotension
Glucagon can be used to reverse beta blockers
1:1000 dilution, 0.3 mg. dose administered IM or SQ q5 minutes as needed to control BP and other symptoms Tourniquet above injection site Pt can use their Epi-pen
Effect of epi can be blunted by beta-blockers, with severe, prolonged sx including bronchospasm, bradycardia, and hypotension
Glucagon can be used to reverse beta blockers
IM vs. SQ EpinephrineIM vs. SQ Epinephrine
Both routes of injection appear in the literature
IM injections into the thigh have been reported to provide more rapid absorption and higher plasma levels than IM or SQ injections into the arm.
Studies directly comparing different routes have not been done
Both routes of injection appear in the literature
IM injections into the thigh have been reported to provide more rapid absorption and higher plasma levels than IM or SQ injections into the arm.
Studies directly comparing different routes have not been done
Interventions continued…Interventions continued…
Establish/maintain airway Give O2/check pulse ox IV access, hang IV fluids with NS Consider:
Diphenhydramine 25-50 mg. IM Albuterol nebulized
Transfer to ED
Establish/maintain airway Give O2/check pulse ox IV access, hang IV fluids with NS Consider:
Diphenhydramine 25-50 mg. IM Albuterol nebulized
Transfer to ED
Measures to reduce dosing errorsMeasures to reduce dosing errors
Educate staff administering Standardize forms & protocols Multiple identity checks: name/DOB One patient in “shot” room Avoid distractions to staff Patient education about systemic reactions
Educate staff administering Standardize forms & protocols Multiple identity checks: name/DOB One patient in “shot” room Avoid distractions to staff Patient education about systemic reactions
Increase administration safety Increase administration safety
Detailed instructions from allergist Develop own step by step process for giving
injections Standardize forms to document injections Standardize treatment for systemic reaction Agreement form for student compliance All staff competency and mock systemic reaction
drill Review of health status before injections
Detailed instructions from allergist Develop own step by step process for giving
injections Standardize forms to document injections Standardize treatment for systemic reaction Agreement form for student compliance All staff competency and mock systemic reaction
drill Review of health status before injections
Review Health Status Before Injections (why you don’t draw injection first)
Review Health Status Before Injections (why you don’t draw injection first)
Current asthma symptoms, ? Measure peak flow Current allergy symptoms and medication use New medications (beta blockers, ACE-I) Delayed reactions to previous injections Compliance with injection schedule New illness (fever), pregnancy Consultation with allergist as needed
Current asthma symptoms, ? Measure peak flow Current allergy symptoms and medication use New medications (beta blockers, ACE-I) Delayed reactions to previous injections Compliance with injection schedule New illness (fever), pregnancy Consultation with allergist as needed
ReferencesReferences
Position Statement on the Administration of Immunotherapy Outside of the Prescribing Allergist Facility, ACAAI, October 1997.
Rank MA, Li JTC. Allergen Immunotherapy. Mayo Clin Proc. 2007;82(9):1119-1123.
Stokes JR, Casale TB. Allergy Immunotherapy for Primary Care Physicians. AJM. 2006;119(10):820-823.
Lieberman P, Kemp SF, Oppenheimer J, et al. The diagnosis and management of anaphylaxis:an updated practice parameter. J Allergy Clin Immunology 2005;115:S483-523.
Li JT, Lockey IL, Bernstein JM, et al. Allergen immunotherapy: a practice parameter. Ann Allergy, Asthma & Immunology.2003;90:1-40.
Position Statement on the Administration of Immunotherapy Outside of the Prescribing Allergist Facility, ACAAI, October 1997.
Rank MA, Li JTC. Allergen Immunotherapy. Mayo Clin Proc. 2007;82(9):1119-1123.
Stokes JR, Casale TB. Allergy Immunotherapy for Primary Care Physicians. AJM. 2006;119(10):820-823.
Lieberman P, Kemp SF, Oppenheimer J, et al. The diagnosis and management of anaphylaxis:an updated practice parameter. J Allergy Clin Immunology 2005;115:S483-523.
Li JT, Lockey IL, Bernstein JM, et al. Allergen immunotherapy: a practice parameter. Ann Allergy, Asthma & Immunology.2003;90:1-40.
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