Paclitaxel (Taxol) Infusion Hypersensitivity Reaction: Case Study and Management

Case Presentation

JT, a middle-aged gentleman receiving paclitaxel (Taxol) infusion for cancer therapy reported extreme fatigue minutes into his infusion, prompting immediate cessation of the infusion after approximately 20 mL was delivered. Neurological assessment revealed slow responsiveness but intact orientation. Vital signs were difficult to obtain due to positioning, and during observation, the patient developed chills, pronounced sweating (diaphoresis), and nausea. Approximately 5 minutes later, the patient described severe chest pain (tight, 8/10), visible distress but without hypoxia on room air. Oxygen via nasal cannula was initiated for chest pain.

Clinical Actions

Infusion was stopped immediately, and the patient was closely monitored per algorithm recommendations for suspected hypersensitivity reactions (HSR).
Providers were rapidly notified; onsite physicians assessed the patient and escalated care with a call to EMS for cardiac evaluation.
Approximately 7 minutes after his chest pain complaint, rescue medications—famotidine (Pepcid), hydrocortisone (Solucortef), diphenhydramine (Benadryl), and epinephrine—were administered as per the algorithm’s management for severe symptoms.
Chest pain, chills, and ongoing symptoms persisted, leading EMS teams to provide further critical intervention and transfer the patient for hospitalization.

Algorithm Alignment

Per MD Anderson’s protocol, actions concerning immediate infusion stoppage, vital monitoring, antihistamine/steroid/epinephrine rescue medication, provider notification, and EMS activation for severe symptoms were fully appropriate. Supportive oxygen was justified for chest pain, and urgent cardiac workup was crucial given symptom progression.

Immediate Response and Assessment

Stopping the Infusion: The Taxol (paclitaxel) infusion was immediately stopped after the onset of symptoms, which is the first step recommended for any signs or symptoms of HSR/allergic reaction per the algorithm.
Assessment: Neurological and vital signs assessment was performed, which matches the algorithm's instruction to monitor symptoms and obtain vital signs every 5 minutes for suspected HSR.

Symptom Development and Escalation

The patient developed chills, diaphoresis, nausea, and chest pain (tightness, 8/10), but did not report shortness of breath and was not hypoxic.
According to the algorithm, for symptoms such as chills, fever, or rigors, the recommended intervention includes stopping the infusion and close monitoring, as was done.
The escalation to chest pain and severe symptoms justifies heightened emergency activation and provider involvement, as indicated by the algorithm's instructions to notify the responding provider and activate emergency response in the presence of significant new symptoms.

Rescue Medications

Although the patient was not hypoxic, supplemental oxygen via nasal cannula was provided for chest pain, which is reasonable for supportive management.
With the onset of persistent severe chest pain, diaphoretic symptoms, and continued distress, the decision to call EMS for further cardiac workup and hospital transfer is appropriate, as cardiac causes must be ruled out and advanced management may be required.

Notification and Documentation

Providers were notified rapidly, and documentation was performed according to institutional protocols, as cited in the algorithm's documentation recommendations.

Summary Table: Scenario vs Algorithm

Step	Scenario Action	Algorithm Recommendation	Alignment
Infusion stopped	Yes	Yes	✓
Neuro/vital sign assessment	Yes	Yes	✓
Provider notified	Yes	Yes	✓
EMS called for chest pain	Yes	Yes (for escalation/severe symptoms)	✓
Allergy rescue meds given	Yes (pepcid, solucortef, benadryl, epinephrine)	Yes (antihistamine, steroid, epi)	✓
Oxygen for chest pain	Yes	Yes (if SpO2 ≤92%, supportive)	✓

Key Takeaways

Early recognition and rapid response for HSR during antineoplastic infusions are essential.
Immediate collaboration between nursing, medical staff, and emergency services ensures comprehensive patient safety.
Following institutional algorithms and documenting actions are vital for best practice and accountability.

Opportunities for Improvement in Hypersensitivity Reaction Management

While the actions taken in this case followed the MD Anderson algorithm for adult hypersensitivity reaction management and were broadly appropriate, there are several areas for potential optimization or best practices that could be considered for even more effective care.

Early Identification and Preemptive Measures

Pre-infusion Risk Assessment: Assessing risk factors for hypersensitivity before Taxol administration—such as prior allergies or reactions—may enable closer monitoring or adjusting premedication protocols for high-risk patients.
Pre-infusion Education: Ensure patients understand the need to promptly report new or unusual symptoms during infusion to improve early detection.

Vital Sign Monitoring and Documentation

Continuous Monitoring: If signs of extreme fatigue or altered neuro status occur, initiate continuous vital sign monitoring earlier. The delay in getting accurate blood pressure due to patient status suggests that additional staff or rapid-access equipment (e.g., automated BP cuff) could have improved early data collection.
Immediate Documentation: Document observations and interventions in real-time to ensure clarity and medico-legal protection. This reinforces algorithm instructions for complete and prompt documentation of hypersensitivity events as observed adverse drug reactions.

Rescue Medication Administration

Route of Epinephrine: Ensure epinephrine is administered IM in the mid-thigh for best absorption and efficacy in severe reactions (the preferred route per algorithm instructions).

Oxygen Therapy

Appropriate Oxygen Use: The algorithm recommends oxygen at 2 L/min for patients with SpO2 ≤ 92%. In this case, oxygen was provided for chest pain (with normal oxygen saturation)—not contraindicated, but its initiation should be dictated primarily by oxygen saturation and symptom severity.

Summary Table: Opportunities for Optimization

Area	Potential Improvement	Algorithm Reference
Early monitoring	Quicker and continuous vital sign access	Monitor every 5 mins, document ADR
Rescue meds	Immediate administration as symptoms escalate	Give meds promptly for severe HSR
Epinephrine route	Confirm IM thigh administration	IM thigh preferred, regardless of platelets
Oxygen usage	Base on SpO2/<92% and not just chest pain	O2 for SpO2 ≤ 92%
Documentation	Real-time charting of interventions and event	Documentation as observed ADR

Conclusion

All major actions in this case—including stopping the infusion, prompt assessment, provider notification, timely rescue medication administration, provision of supportive oxygen, and EMS activation for cardiac evaluation—were appropriate and fully supported by the MD Anderson adult hypersensitivity reaction management algorithm. The response was thorough and aligned with best-practice standards for chemotherapeutic hypersensitivity reactions; however, future care could be further optimized by prioritizing rapid, real-time vital sign monitoring, immediate IM epinephrine administration, strict oxygen guideline adherence, meticulous documentation, and enhanced patient/staff education about hypersensitivity risks, leading to even safer and more systematic infusion management.

Additional Resources

See a visual guide based on MD Anderson algorithm for systemic management, flashcard reviews, and additional case quiz.

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

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