Management of Anaphylaxis During Immunoglobulin Infusion

Immediate Conduct in Anaphylaxis

The American College of Physicians recommends immediate interruption of immunoglobulin infusion and administration of epinephrine 0.2-0.5 mg intramuscularly in the lateral thigh, repeating every 5-15 minutes if necessary, while maintaining venous access and initiating aggressive volume resuscitation 1, 2, 3
Initial critical steps include stopping the infusion immediately and maintaining intravenous access, evaluating ABC (airway, breathing, and circulation) and level of consciousness, positioning the patient appropriately, administering oxygen as needed, and calling for medical assistance immediately 2, 3, 4

The European Resuscitation Council recommends epinephrine (first-line treatment) with a dose of 0.01 mg/kg (dilution 1 mg/mL, maximum 0.5 mL total) intramuscularly in the lateral thigh, repeating every 5-15 minutes if there is no response 1, 2, 3
The American Heart Association suggests that anti-histamines (adjuvant therapy) such as diphenhydramine 50 mg IV combined with ranitidina 50 mg IV should be administered 1, 3
Corticosteroids, such as a dose equivalent to 1-2 mg/kg of methylprednisolone IV every 6 hours, are effective in preventing biphasic reactions but are not critical in the acute management of anaphylaxis 1, 2, 3, 4

For bradycardia, atropine 600 mcg IV should be administered 1, 3
For patients on beta-blockers, glucagon 1-5 mg IV in infusion over 5 minutes, followed by continuous infusion (5-15 mg/min) titrated according to clinical response, should be given 1, 3

Continuous monitoring of vital signs until complete resolution of symptoms is recommended 2, 3, 4
Observation for 24 hours is recommended after a severe reaction due to the risk of biphasic reactions 1, 2, 4

Absolute contraindications for new attempts include true anaphylaxis or grade 3 or higher CTCAE reactions 2, 3, 4
If a new attempt is considered in mild to moderate reactions, it should be done after complete resolution of symptoms, with a reduced infusion rate and additional pre-medication (corticosteroids and anti-histamines) 2, 4

Do not delay epinephrine administration while waiting for anti-histamines or corticosteroids to take effect, as this increases mortality and the risk of biphasic reactions 5
Do not confuse vasovagal reaction with anaphylaxis: vasovagal reaction presents with bradycardia and pallor without cutaneous manifestations, while anaphylaxis typically causes tachycardia and urticaria 5