13.2 Oncologic Emergencies II: Hypersensitivity & Anaphylaxis, Sepsis, Pleural Effusion & Thromboembolism
Key Takeaways
Paclitaxel and docetaxel reactions usually occur in the first or second dose within minutes, whereas carboplatin reactions typically appear after several cycles because they are IgE-mediated.
For anaphylaxis, the nurse stops the infusion, calls for help, and gives intramuscular epinephrine (0.01 mg/kg, maximum 0.5 mg in adults) into the anterolateral thigh while supporting airway and circulation.
Surviving Sepsis Campaign guidance calls for blood cultures and broad-spectrum antibiotics within 1 hour for suspected septic shock, with norepinephrine as first-line vasopressor for a mean arterial pressure target of 65 mm Hg.
Breast cancer is the second most common cause of malignant pleural effusion, and recurrent effusions are managed with an indwelling pleural catheter or talc pleurodesis.
ASCO guidance supports direct oral anticoagulants or low-molecular-weight heparin for cancer-associated thrombosis for at least 6 months, with extra caution about bleeding risk and drug interactions.
Hypersensitivity Reactions and Anaphylaxis
High-Risk Agents in Breast Cancer
| Agent | Mechanism and timing | Prevention |
|---|---|---|
| Paclitaxel | Often related to the Cremophor EL vehicle; usually the first or second infusion, within the first minutes | Premedication with dexamethasone, an H1 blocker, and an H2 blocker |
| Docetaxel | Polysorbate 80 vehicle; early in the infusion | Dexamethasone premedication (also prevents fluid retention) |
| Carboplatin | IgE-mediated sensitization; typically after several cycles | Awareness of cumulative exposure; skin testing or desensitization after a reaction |
| Trastuzumab, pertuzumab, sacituzumab | Infusion-related reactions, mostly with the first dose | Premedication per protocol, slower initial rate, observation periods |
Distinguish a standard infusion reaction (cytokine-mediated fever, chills, flushing) from anaphylaxis (rapid multisystem involvement: urticaria or angioedema plus respiratory compromise, hypotension, or gastrointestinal symptoms).
Emergency Actions (ONS and Allergy Guidance)
- Stop the infusion immediately; keep the IV line open with normal saline using new tubing.
- Stay with the patient and call for help (rapid response).
- Assess airway, breathing, circulation, and level of consciousness; place the patient supine with legs elevated (or sitting if dyspneic).
- For anaphylaxis, give intramuscular epinephrine 0.01 mg/kg (0.3 to 0.5 mg for adults) into the anterolateral thigh; repeat every 5 to 15 minutes if needed.
- Give oxygen and an IV fluid bolus for hypotension.
- Adjuncts after epinephrine: H1 and H2 antihistamines, corticosteroids, and bronchodilators for wheezing.
- Monitor for biphasic reactions, document, and report.
Rechallenge after a mild taxane reaction is often possible with a slower rate and additional premedication. After anaphylaxis or carboplatin reactions, rechallenge requires allergist input and a desensitization protocol. Emergency equipment and drugs must be at the chairside for every infusion.
Sepsis and Septic Shock
Sepsis is life-threatening organ dysfunction caused by a dysregulated response to infection (Sepsis-3). Septic shock is sepsis requiring vasopressors to keep mean arterial pressure at 65 mm Hg or above with lactate above 2 mmol/L despite adequate fluids. Patients receiving chemotherapy, those with central lines, and those with neutropenia may not show fever or localizing signs.
Recognition clues include new confusion, respiratory rate of 22 or higher, systolic blood pressure of 100 or lower, low urine output, mottled skin, and rising lactate. Early warning scores and nurse-driven sepsis screening speed detection.
Key actions from the Surviving Sepsis Campaign (2021):
- Obtain blood cultures before antibiotics without delaying them.
- Give broad-spectrum antibiotics within 1 hour for possible septic shock or high likelihood of sepsis.
- Give 30 mL/kg of crystalloid within 3 hours for sepsis-induced hypotension or high lactate, reassessing fluid responsiveness.
- Measure lactate and repeat it if elevated.
- Use norepinephrine as the first-line vasopressor for a MAP target of 65 mm Hg.
- Evaluate and remove infected catheters when indicated.
Febrile neutropenia (covered with chemotherapy toxicities) follows the same 1-hour principle.
Malignant Pleural Effusion
Breast cancer is the second most common cause of malignant pleural effusion after lung cancer. Patients report progressive dyspnea, cough, and chest heaviness; examination shows decreased breath sounds and dullness to percussion.
- Diagnosis: chest radiograph, ultrasound, or CT; thoracentesis for cytology and symptom relief.
- Thoracentesis safety: remove a limited volume (commonly no more than about 1 to 1.5 L at one time) and stop for chest pain, persistent cough, or dyspnea to avoid re-expansion pulmonary edema. Monitor for pneumothorax afterward.
- Recurrent effusions: an indwelling pleural catheter allows home drainage and may lead to spontaneous pleurodesis; talc pleurodesis is another option when the lung re-expands.
- Nursing teaching for indwelling catheters: sterile drainage technique, drainage schedule (often every other day or as symptoms require), dressing care, and signs of infection or catheter blockage.
Venous Thromboembolism
Cancer raises venous thromboembolism (VTE) risk several-fold. Breast cancer-specific risk factors include tamoxifen, raloxifene, chemotherapy, abemaciclib, central venous catheters, surgery, immobility, and metastatic disease.
- Signs: unilateral leg swelling, calf pain, warmth, or redness (DVT); sudden dyspnea, pleuritic chest pain, tachycardia, or hypoxia (PE). Arm swelling on the side of a port may signal catheter-related thrombosis.
- Diagnosis: compression duplex ultrasound for DVT; CT pulmonary angiography for PE.
- Treatment: ASCO guidance supports direct oral anticoagulants (apixaban, edoxaban, or rivaroxaban) or low-molecular-weight heparin for at least 6 months and while cancer is active. LMWH may be preferred when bleeding risk is high (for example, gastrointestinal or genitourinary lesions) or when drug interactions or absorption are concerns.
- Prevention: pharmacologic prophylaxis after major surgery and for hospitalized patients; for ambulatory patients starting chemotherapy with a Khorana score of 2 or higher, prophylaxis with apixaban, rivaroxaban, or LMWH may be offered.
- Nursing role: teach warning signs, encourage mobility and hydration, review interactions (strong CYP3A4 and P-glycoprotein inhibitors and inducers affect DOAC levels), monitor for bleeding, and coordinate anticoagulation around procedures.
Triage Summary
| Presenting problem | Possible emergency | Immediate action |
|---|---|---|
| Flushing, hives, wheeze, or hypotension during an infusion | Hypersensitivity or anaphylaxis | Stop infusion, call for help, IM epinephrine for anaphylaxis |
| Fever, confusion, low blood pressure, or rapid breathing | Sepsis or septic shock | Cultures and antibiotics within 1 hour, fluids, escalate care |
| Progressive shortness of breath with dull, quiet lung base | Malignant pleural effusion | Imaging and thoracentesis |
| One swollen, painful leg or sudden pleuritic chest pain | DVT or pulmonary embolism | Urgent evaluation and imaging; anticoagulation |
Tumor lysis syndrome and disseminated intravascular coagulation are rare in breast cancer but can occur with bulky, rapidly responding metastatic disease; watch for rising potassium, phosphate, uric acid, and creatinine, or for unexplained bleeding and low platelets.
Five minutes into a first paclitaxel infusion, a patient develops generalized hives, lip swelling, wheezing, and a blood pressure of 78/40 mm Hg. After stopping the infusion and calling for help, what is the priority medication?
Oral diphenhydramine
Intramuscular epinephrine into the anterolateral thigh
IV furosemide
A second dose of dexamethasone premedication and resumption of the infusion at half rate
During thoracentesis for a malignant pleural effusion, the patient develops a persistent cough and chest tightness after 1.2 L has been removed. What should the nurse anticipate?
Stopping fluid removal to reduce the risk of re-expansion pulmonary edema
Continuing until the effusion is completely drained regardless of symptoms
Placing the patient in Trendelenburg position to speed drainage
Giving a fluid bolus of 2 L to prevent hypotension
A patient with metastatic breast cancer on capecitabine is diagnosed with a proximal DVT. She has no gastrointestinal or genitourinary lesions and no interacting medications. Which management is consistent with ASCO guidance?
Aspirin 81 mg daily for 1 month
Warfarin without monitoring
No anticoagulation, because cancer-associated clots resolve on their own
A direct oral anticoagulant such as apixaban, or low-molecular-weight heparin, for at least 6 months
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