Drug allergy peer feedback-Jodie Brakstad

Drug interactions is a type 1 hypersensitivity reaction. Beta lactam is in antibiotic drugs; usually this assists with treating different things such as sinusitis, or infection prophylaxis. IgE and T cells have mediated mechanisms where antibiotics bind to sites such as the T cell receptors on MHC which in turn activates the immune response.

Side effects occur within 30-60 minutes, and present as hives, angioedema, swelling in the tongue, lips, face, airways, hypotension, or anaphylaxis.

The first exposure was IV ampicillin; the APC’s recognized the antigen in the beta lactam compound form. APC’s then digested and presented it to the T helper cells where they took the information and formed a response including the B cells. Specific IgE antibodies were formed and produced by B cells. After this, these IgE were either bound to mast cells, basophils, or were free floating. This is the sensitization period.

The second exposure was at the dental appointment where Emily took amoxicillin. A similar process is started where beta lactam is digested, APC’s bring this to the T cells who recognize it and engage B cells to send off IgE antibodies. Now the antibodies are re-sensitized.

The third exposure is at the dentist again where Emily took amoxicillin. The mast cells and basophils are still sensitized and have IgE ready. This time, APC’s see beta lactam antigens, the T cells engage the B cells to produce more IgE while the pre-existing IgE are at the site. The antigens bind to IgE antibodies on the mast cells and basophils bringing other receptor sites causing the mast cell to lysis in turn releasing histamine, cytokines and prostaglandins. This response leads to vasodilation, allowing fluid and plasma proteins to escape.

Originally, the first symptom was a foot rash; after the 3^rd exposure, we saw swelling off the tongue, throat and lips, and a heightened respiration rate.

The treatment was 25mg diphenhydramine hydrochloride to decrease the swelling and rash. The follow up care included monitoring blood pressure, airways, and give medication to control her heart rate as needed throughout the recovery process.

The testing performed after this was intradermal testing of IgE levels. The teaching that followed involved avoiding these two antibiotics in the future, and to stick to other penicillin’s.

The content discussed throughout the podcast was very thorough and interesting; however; I feel there are areas that could have been dived into deeper.

I really liked how the symptoms were relayed a few times throughout the podcast to reiterate how important they are. I think it could have been enhanced if further symptoms were discussed such as tingling or itching, anxiety etc.

I also think it could be beneficial to touch on certain topics such as biphasic reactions, which is why it is so important to monitor patients after we give treatment in the hospital before we discharge. Since biphasic reactions can occur as late as 3 days after taking the medication. It would be another important teaching moment throughout discharge, and could be something all nursing students bring forward with their practice.

Regarding the points made about increasing permeability and vasodilation, I think it could have been beneficial to discuss the pathophysiology further behind why this happens. For example, further discussing how histamine is responsible for these effects, and how capillary vasodilation and permeability together lead to the tachycardia and hypotension we see in patients.

While this is not necessarily a gap, I would be interested to learn what would happen in the case that someone may have an allergic drug reaction to the treatment-diphenhydramine hydrochloride. While I am sure this is a rare occurrence, I wonder if there is alternative treatment options, or what the best other route for treatment would be in a case like this?

Finally, I think it could have been intriguing to deep dive further into the IgE testing that is done to diagnose an anaphylactic patient. How are these performed? Are there contraindications or any other possible options Emily had in that instance?

The way the content was relayed was very informative, insightful and interesting. I really liked that there was a spin on it being more of a true crime style podcast. The concept of repetition really helped my learning and understanding throughout listening to the podcast. Many key ideas were repeated throughout the podcast such as the signs and symptoms, sensitization period, and IgE being an overreactive player in a hypersensitivity 1 response.

Along with the repetition, I really liked how it was broken into different phases throughout the podcast. There was a broad overview at the beginning to give the listeners an idea of what to expect, and then it was further broken down into the different phases where we as listeners were able to digest the different concepts in detail. Being able to see the big picture first, and then see what different key players such as “cillin the villain”, IgE, B cells and T cells roles were throughout this reaction helped listeners digest this information into stages which is often a helpful learning tactic for me.

There was also a really good mix between pathophysiology language as well as storytelling throughout the podcast which enhances the interest of the listener to engage in the content. Sometimes if it was more focused on the pathophysiology language it can tend to be less engaging, or if it was only focused on story telling. I thought there was a really great mix between informative information as well as a captivating story to engage the audience!

This video was thought out and produced very well, however the one change that I would recommend would be to incorporate a second case throughout the podcast. While I completely understand there is a time limit which can hinder the ability to incorporate this, I think it would be beneficial to learners to see another case that may go differently than Emily’s to further enhance the learners understanding of the content.

For example, an interesting avenue that could have been explored could have been a drug allergy, but not a true drug allergy. As discussed in class, often times a drug incompatibility or interaction is mistaken for a drug allergy. Many people are sensitive but not allergic to certain drugs. Maybe a second case where another individual came in experiencing symptoms, the patient was tested and treated accordingly, leading to us understanding the different between a true drug allergy and a sensitivity. This could have also shed light onto the comprehension of drug interactions as well and how this can produce similar symptoms sometimes, and how to differentiate the two.

Another way to incorporate a second case could have been by lengthening Emily’s case further. This could have been done by Emily experiencing a biphasic reaction. This could be where she was treated but was not fully recovering, or where she went home and experienced symptoms again. This could lead into further discussion regarding the follow up care, treatment, and discharge teaching that needs to be done with patients experiencing a true drug allergy along with a biphasic reaction. Overall, it was very well done however these few key ideas could have been a great addition as well.

There were many great key takeaways that were presented throughout this podcast that I will bring forward into practice. Even the way the content was relayed throughout the podcast is an amazing takeaway; knowing that information can be presented in ways that are interesting to listeners, but also provide great insight into the ways in which we recognize and treat drug allergies. I also think this is a great reminder for when we are working with children, we need to be creative in the ways in which we portray information so they can understand the information while we make it interesting for them.

One of the main pieces of content that was discussed that I will integrate into my practice is recognizing symptoms that may appear to be small to the patient, but is a key detail in understanding drug allergies. When Emily experienced itchiness to her foot, this was the first symptom that was displayed indicating that she was having a drug allergy. This goes to show that just because a symptom may feel small in the moment, we cannot take away the importance of asking patients their history with the drug, and understanding whether or not someone has been through the sensitization period.

While I plan to go into the ED after graduation, this case is a great learning opportunity because I have already seen a few drug allergies, and I am sure I along with many other students will see more throughout our time being a registered nurse in the future. It is so important to remember that just because someone has had a medication before with no reaction, this does not mean that we get to write off the possibility of an allergic reaction happening. This is why monitoring patients is so important in nursing, and doing teaching with patients to tell us if they are experiencing any symptoms at all so we can monitor them and treat them appropriately. Since these reactions occur so quickly, it is imperative that we recognize the symptoms, and get treatment for them as soon as possible. Overall, it was a very well-done and informative podcast, so great job team!