Managing Cytokine Release Syndrome

 

Nurses may not recognize the early signs of cytokine release syndrome (CRS) if they are not experienced with administering immune-based therapies. CRS can be observed following the administration of immune-based therapies, such as rituximab and other monoclonal antibodies. It also may appear with such treatments as infusion of chimeric antigen receptor–modified T cells (CAR-T cells) done at specialized academic centers.

CRS is characterized by symptoms such as fever, nausea, chills, hypotension, tachycardia, asthenia, headache, rash, scratchy throat, and dyspnea. Some patients may experience severe life-threatening reactions as a result of a massive release of cytokines.

At the 2015 annual meeting of the Oncology Nursing Society, Anne M. Kolenic, MSN, RN, AOCNS, University Hospitals Seidman Cancer Center, Cleveland, OH, presented a simulation of a case that occurred at a busy infusion center and was managed by an experienced inpatient oncology nurse who was seeing the signs of CRS for the very first time. Kolenic gave the audience recommendations on how to manage the beginning signs of the syndrome so as to avoid full-blown CRS.

Assessing and Managing CRS

The patient was a 52-year-old woman recently diagnosed with non-Hodgkin lymphoma who presented to the clinic for her first infusion of R-CHOP (rituximab-CHOP chemotherapy). CRS in response to rituximab typically occurs during the first infusion.

The patient had a history of hypertension, hypercholesterolemia, allergy to bee stings, and she reported feeling anxious. The patient had been told not to take her antihypertensive agents 12 hours prior to receiving the first rituximab infusion because rituximab has the potential to lower blood pressure, so the blood pressure could drop dangerously.

Rituximab is given alone on day 1 to determine if the patient will have a reaction to the drug. The nurse should tell the patient to let her know right away if she experiences any of the following symptoms: weakness, dizziness, shortness of breath, hives, swelling of the lips, low blood pressure, scratchy throat, itchiness, nausea, or hoarse voice.

“The patient should be monitored closely after the first dose of rituximab,” Kolenic said. “Reactions are most likely with the first dose of a monoclonal antibody, and this patient has a history of allergic reaction. Eighty percent of fatal reactions are associated with the first dose.”

Thirty minutes before receiving a first dose of rituximab, or any monoclonal antibody that can cause CRS, the nurse should give the patient Tylenol plus Benadryl. Prior to starting rituximab, or any monoclonal antibody infusion related to cytokine release, the nurse should have an emergency medical kit available, Kolenic continued.

The infusion should be started slowly, and the patient should be reminded to use the call bell to alert the nurse if any of the symptoms mentioned above emerge. A headache that occurs after 20 minutes could be an initial sign of CRS.

“Sometimes a reaction will start out subtly, with nausea, headache, rash, or just not feeling right. Never underestimate what a patient is telling you. Do not leave the patient,” Kolenic told listeners.

At the first sign of any of the symptoms mentioned above, the rituximab infusion should be stopped, and the nurse should call for assistance, giving the patient normal saline and getting emergency medications ready. The first step in assessing the patient is to monitor vital signs every 5 minutes while any of the symptoms are present, Kolenic emphasized. If any signs of bronchial constriction appear, administer epinephrine; then opening the airway is the next important step. Give the patient Benadryl, and an H² and H¹ blocker to counteract the unwanted effects of Benadryl, Kolenic advised.

Kolenic noted that even though steroids such as methylprednisolone are included in standing emergency orders, there is scant evidence in support of their use.

If the patient’s vital signs begin to improve 15 minutes later, the rituximab infusion can be resumed at a 50% reduction, with slow titration every 30 minutes based on response. Often, this can be achieved safely with no further symptoms, Kolenic said. Once the patient has received the rituximab infusion and has had no further problems, she can go home. However, give her a phone contact she can call if any symptoms start to appear prior to coming in for the next-day infusion, Kolenic advised.

Reference
Kolenic A. Cytokine release syndrome—oh my! Presented at: Oncology Nursing Society 40th Annual Congress; April 22-26, 2015; Orlando, FL.