This protocol governs the recognition and management of infusion, hypersensitivity, and anaphylactic reactions in all patients receiving infusion therapy at Springside Infusion, including biologics, monoclonal antibodies, antibiotics, immunoglobulin, and other parenteral medications. These standing orders remain in effect for all infusion patients unless otherwise specified in writing by the ordering provider.
Observe for Signs of a Reaction
Fever, chills, rigors, flushing, pruritus, rash or hives, cough, sneezing, throat irritation, nausea, vomiting, chest tightness, back pain, headache, joint pain, shortness of breath, wheezing, hypotension, hypertension, angioedema (swelling of the mouth, tongue, lips, or airway), or altered mental status.
Reaction Severity Grading (CTCAE-based)
General Procedure for Suspected Reactions: If the patient presents with any of the above symptoms, the nurse must
Step 1: Stop the infusion and notify the on-call provider.
Step 2: Identify the reaction grade using the criteria above and treat per the corresponding protocol below.
Step 3: Establish/ maintain IV access.
Step 4: Record vital signs at the time of reaction and at regular intervals until reaction resolution.
Step 5: Document the time of reaction, interventions performed, patient vitals, medications administered, and patient response on the Infusion Reaction Documentation Form.
Step 6: Monitor the patient for at least 30 minutes following resolution of symptoms, or longer per provider direction.
Call 911 immediately if the patient does not improve, becomes unstable, or worsens at any point.
MILD REACTION MANAGEMENT — GRADE 0–1
Presentation: mild flushing, pruritus, localized rash or hives; vital signs stable.
Step 1: Stop the infusion; keep the IV line open with normal saline. Do not remove the IV.
Step 2: The nurse may administer: Famotidine 20 mg IV push, Diphenhydramine 25 mg IV push, Acetaminophen 500-1000 mg PO, Ibuprofen 400mg, and 500 mL normal saline IV bolus.
Step 3: Contact the on-call provider
Step 4: Monitor symptoms for at least 15 minutes. If symptoms persist or worsen, proceed to Moderate Reaction Management below.
Step 5: Continue monitoring for at least 30 minutes or until symptoms fully resolve.
Step 6: Infusion may resume per medication protocol only with provider permission.
MODERATE REACTION MANAGEMENT — GRADE 2–3
Presentation: significant flushing, chest tightness without instability, diffuse hives or pruritus, rigors, urticaria, nausea/vomiting, joint pain, fever >100.5°F, hypotension, hypertension, or shortness of breath without respiratory distress.
Step 1: Stop the infusion. Keep the IV line open with normal saline; do not remove the IV.
Step 2: The nurse may administer: Diphenhydramine 50 mg IV push, Methylprednisolone 125 mg IV push, Famotidine 20mg IV Push, Ondansetron 4 mg slow IV push over 5 minutes, Acetaminophen 650 mg PO, and Normal Saline 1000 mL IV bolus.
Step 3: An additional 1000 mL normal saline bolus may be repeated for a systolic blood pressure below 90.
Step 4: Position the patient with legs elevated as needed for hypotension.
Step 5: Notify the on-call provider.
Step 6 If two or more organ systems are involved, escalate immediately to Severe Reaction / Anaphylaxis management.
Step 7: Monitor patient until symptom resolution and vital signs are stable for at least 30-60 min prior to discharge
SEVERE REACTION / SUSPECTED ANAPHYLAXIS — GRADE 4
Presentation: respiratory distress, wheezing/bronchospasm, airway swelling, hypotension, syncope, or rapid progression of symptoms.
If a patient presents with severe reaction/anaphylaxis symptoms, the nurse should
Step 1: Stop the infusion immediately. Disconnect IV tubing; do not flush the line.
Step 2: Administer Epinephrine 0.3 mg IM in the mid-outer thigh immediately. May be repeated every 5–15 minutes for a maximum of 2 doses.
Step 3: Call 911. Announce the emergency and initiate the facility emergency response.
Step 4: Position the patient supine with legs elevated; semi-reclined if in respiratory distress.
Step 5: Administer high-flow oxygen 10–15 L/min via non-rebreather mask.
Step 6: Establish a second IV line if possible and give a normal saline 1000ml to 2000ml bolus for hypotension.
Step 7: Administer as supporting medications once epinephrine is given:
Diphenhydramine 50 mg IV push, Famotidine 20 mg IV Push, and Methylprednisolone 125 mg IV Push.
Step 8: Notify the on-call provider by voice as soon as possible with the medication name, dose, onset time, and current vital signs.
Step 9: Complete the Infusion Reaction Documentation Form and provide a full EMS handover, including drug, lot, dose, onset, and all medications given.
Disposition & Follow-Up
Provider Acknowledgment
By referring a patient to Springside Infusion, the referring provider confirms review of this Adverse & Hypersensitivity Reaction Management Protocol and grants authorization for Springside Infusion and its Registered Nurses to implement these standing orders for any patient under their care who experiences a suspected infusion reaction, unless the referring
This protocol governs the recognition and management of infusion, hypersensitivity, and anaphylactic reactions in all patients receiving infusion therapy at Springside Infusion, including biologics, monoclonal antibodies, antibiotics, immunoglobulin, and other parenteral medications. These standing orders remain in effect for all infusion patients unless otherwise specified in writing by the ordering provider.
Observe for Signs of a Reaction
Fever, chills, rigors, flushing, pruritus, rash or hives, cough, sneezing, throat irritation, nausea, vomiting, chest tightness, back pain, headache, joint pain, shortness of breath, wheezing, hypotension, hypertension, angioedema (swelling of the mouth, tongue, lips, or airway), or altered mental status.
Reaction Severity Grading (CTCAE-based)
General Procedure for Suspected Reactions: If the patient presents with any of the above symptoms, the nurse must
Step 1: Stop the infusion and notify the on-call provider.
Step 2: Identify the reaction grade using the criteria above and treat per the corresponding protocol below.
Step 3: Establish/ maintain IV access.
Step 4: Record vital signs at the time of reaction and at regular intervals until reaction resolution.
Step 5: Document the time of reaction, interventions performed, patient vitals, medications administered, and patient response on the Infusion Reaction Documentation Form.
Step 6: Monitor the patient for at least 30 minutes following resolution of symptoms, or longer per provider direction.
Call 911 immediately if the patient does not improve, becomes unstable, or worsens at any point.
MILD REACTION MANAGEMENT — GRADE 0–1
Presentation: mild flushing, pruritus, localized rash or hives; vital signs stable.
Step 1: Stop the infusion; keep the IV line open with normal saline. Do not remove the IV.
Step 2: The nurse may administer: Famotidine 20 mg IV push, Diphenhydramine 25 mg IV push, Acetaminophen 500-1000 mg PO, Ibuprofen 400mg, and 500 mL normal saline IV bolus.
Step 3: Contact the on-call provider
Step 4: Monitor symptoms for at least 15 minutes. If symptoms persist or worsen, proceed to Moderate Reaction Management below.
Step 5: Continue monitoring for at least 30 minutes or until symptoms fully resolve.
Step 6: Infusion may resume per medication protocol only with provider permission.
MODERATE REACTION MANAGEMENT — GRADE 2–3
Presentation: significant flushing, chest tightness without instability, diffuse hives or pruritus, rigors, urticaria, nausea/vomiting, joint pain, fever >100.5°F, hypotension, hypertension, or shortness of breath without respiratory distress.
Step 1: Stop the infusion. Keep the IV line open with normal saline; do not remove the IV.
Step 2: The nurse may administer: Diphenhydramine 50 mg IV push, Methylprednisolone 125 mg IV push, Famotidine 20mg IV Push, Ondansetron 4 mg slow IV push over 5 minutes, Acetaminophen 650 mg PO, and Normal Saline 1000 mL IV bolus.
Step 3: An additional 1000 mL normal saline bolus may be repeated for a systolic blood pressure below 90.
Step 4: Position the patient with legs elevated as needed for hypotension.
Step 5: Notify the on-call provider.
Step 6 If two or more organ systems are involved, escalate immediately to Severe Reaction / Anaphylaxis management.
Step 7: Monitor patient until symptom resolution and vital signs are stable for at least 30-60 min prior to discharge
SEVERE REACTION / SUSPECTED ANAPHYLAXIS — GRADE 4
Presentation: respiratory distress, wheezing/bronchospasm, airway swelling, hypotension, syncope, or rapid progression of symptoms.
If a patient presents with severe reaction/anaphylaxis symptoms, the nurse should
Step 1: Stop the infusion immediately. Disconnect IV tubing; do not flush the line.
Step 2: Administer Epinephrine 0.3 mg IM in the mid-outer thigh immediately. May be repeated every 5–15 minutes for a maximum of 2 doses.
Step 3: Call 911. Announce the emergency and initiate the facility emergency response.
Step 4: Position the patient supine with legs elevated; semi-reclined if in respiratory distress.
Step 5: Administer high-flow oxygen 10–15 L/min via non-rebreather mask.
Step 6: Establish a second IV line if possible and give a normal saline 1000ml to 2000ml bolus for hypotension.
Step 7: Administer as supporting medications once epinephrine is given:
Diphenhydramine 50 mg IV push, Famotidine 20 mg IV Push, and Methylprednisolone 125 mg IV Push.
Step 8: Notify the on-call provider by voice as soon as possible with the medication name, dose, onset time, and current vital signs.
Step 9: Complete the Infusion Reaction Documentation Form and provide a full EMS handover, including drug, lot, dose, onset, and all medications given.
Disposition & Follow-Up
Provider Acknowledgment
By referring a patient to Springside Infusion, the referring provider confirms review of this Adverse & Hypersensitivity Reaction Management Protocol and grants authorization for Springside Infusion and its Registered Nurses to implement these standing orders for any patient under their care who experiences a suspected infusion reaction, unless the referring
