The MD Anderson algorithm provides a structured, step-by-step guide to ensure patient safety and timely treatment. Below is an explanation of how to use the algorithm effectively.

1. Starting Point: Recognize Presenting Symptoms

The algorithm begins with the nurse identifying any signs or symptoms of hypersensitivity during infusion. Key categories include:

  • Mild symptoms: hives (urticaria), rash, itching, flushing.
  • Moderate symptoms: fever, chills, rigors.
  • Severe symptoms: hypotension (SBP <90 mmHg or drop >20 mmHg), wheezing, shortness of breath, swelling of face/lips/tongue.

👉 At this step, your role is to immediately stop the infusion and notify the Responding Provider (attending physician, covering provider, or advanced practice provider) while activating your emergency process.

2. Immediate Safety Actions

Regardless of severity:

  • Stop infusion.
  • Monitor vital signs every 5 minutes.
  • Stay with the patient and check oxygen saturation (SpOâ‚‚ continuously).
  • If SpOâ‚‚ ≤ 92%, initiate oxygen at 2 L/min via nasal cannula.

This ensures rapid stabilization while treatment decisions are made.

3. Medication Management by Symptom Type

The algorithm tailors interventions based on symptom severity and premedication status:

a. Hives, Rash, Itching, Flushing

  • If no diphenhydramine was given within the last 30 minutes:
    → Administer diphenhydramine 50 mg IV push over 2 minutes.
  • If diphenhydramine was given within 30 minutes:
    → Repeat diphenhydramine 50 mg IV + cetirizine 10 mg PO.

b. Fever, Chills, Rigors

  • If no recent diphenhydramine:
    → Hydrocortisone 100 mg IV, repeat diphenhydramine 50 mg IV, + cetirizine 10 mg PO.
  • If diphenhydramine given within 30 minutes:
    → Hydrocortisone 100 mg IV + repeat diphenhydramine.

c. Severe Reactions (Hypotension, Wheezing, Airway Swelling)

  • Epinephrine 0.5 mg IM (1 mg/mL concentration) in the thigh (preferred).
  • Follow with:
    • Diphenhydramine 50 mg IV (if not given in last 30 minutes).
    • Hydrocortisone 100 mg IV push.
  • Start normal saline at 150 mL/hr IV for support.
  • Continue to monitor closely with the emergency team.

4. Evaluation and Escalation

Once initial medications are administered:

  • Reassess patient response within 5 minutes.
  • Improvement → continue monitoring and follow provider instructions.
  • No improvement or worsening → escalate with emergency response team.

5. Documentation Requirements

The algorithm emphasizes proper documentation:

  • Use HSR/Allergy order sets.
  • Record as an Observed Adverse Drug Reaction (ADR).
  • Include details of symptoms, interventions, and outcomes.

6. Special Considerations

  • Corticosteroid caution: Some chemotherapy/biotherapy agents avoid steroids, but in severe reactions, corticosteroids should still be given.
  • Epinephrine administration site: Thigh is preferred; deltoid can be used if thigh inaccessible.
  • Stem cell transplant patients: Extra caution—acetaminophen and antihistamine premedication strategies are noted in the algorithm.

Why are stem cell transplant patients different?

Patients undergoing stem cell transplantation (SCT) are at especially high risk of infusion-related reactions because:

  • They receive large volumes of cellular products or donor infusions.
  • They are already immunocompromised and at risk of infection, cytokine release, or allergic-type reactions.
  • Infusion reactions in this group can be harder to distinguish from other post-transplant complications such as infection, engraftment syndrome, or graft-versus-host disease.

Because of this, the algorithm builds in extra caution with premedication.

What is the acetaminophen premedication strategy?

  • Standard recommendation: Give acetaminophen 1,000 mg PO for 1 dose before infusion.
  • Rationale:
    • Helps blunt fever and rigors that are common during cellular infusions.
    • Prevents masking of early febrile reactions, but balances comfort and safety.
  • In SCT patients: This step is emphasized even more strongly because fever may signal both HSR or infection/early sepsis. Nurses must still assess carefully whether fever resolves after intervention or persists (which may mean infection, not just reaction)

What is the antihistamine premedication strategy?

  • Diphenhydramine is the cornerstone:
    • If no antihistamine was given within 30 minutes of the reaction, administer 50 mg IV push.
    • If diphenhydramine was already given within 30 minutes, repeat diphenhydramine 50 mg IV plus cetirizine 10 mg PO.
  • Why this matters for SCT:
    • Antihistamines reduce histamine-mediated urticaria, rash, and flushing, which are very common during donor product infusions.
    • Timing is critical — if given too early (more than 30 minutes before infusion), its protective effect wanes during the high-risk window.

What are the nursing implications?

  • Strict adherence to timing
    • Premedications (acetaminophen + diphenhydramine) should be given as close to infusion as possible, ideally within 30 minutes.
    • If symptoms occur despite premedication, re-dose according to algorithm guidance.
  • Don’t overlook fever
    • Even with acetaminophen on board, monitor for persistent fever after intervention.
    • Distinguish between a drug/infusion reaction and a possible infectious cause, which in SCT patients can be life-threatening.
  • Document premedication timing clearly
    • Note exact time acetaminophen and antihistamines were given relative to infusion start.
    • This information guides decisions if repeat dosing is required during a reaction.

Key Takeaways for Nurses

  • Act fast: Stop infusion, monitor, notify provider, activate emergency response.
  • Use the algorithm by symptom type: Match patient’s presentation with the correct medication pathway.
  • Escalate without delay for severe symptoms—epinephrine is lifesaving.
  • Document thoroughly to support continuity of care and pharmacovigilance.

By following this stepwise approach, infusion nurses can ensure prompt, safe, and evidence-based management of hypersensitivity and allergic reactions during therapy.

Infographic: Rapid, bedside guide for nursing staff

View algorithm visually but in simpler terms for quick chairside reference.

https://info.pharkeep.com/infusion-reaction-guide

Related Article

Why Stem Cell Transplant Patients Need Extra Premedication Precautions
Stem cell transplant patients face higher infusion reaction risks. Extra caution with acetaminophen and antihistamine premedication is critical, along with strict timing, fever vigilance, and precise nursing documentation.
PharKeep DigestKevin Van, PharmD, BCPS (Editor)

Reference

Adult Hypersensitivity (HSR)/Allergic Reaction Management
University of Texa MD Anderson Cancer Center, V9, approved 8/19/2025
https://media.pharkeep.com/view?m=T52MhGqXA