What to do in case of sudden hypotension toward the end of an infusion?

Management of Sudden Hypotension During IV Iron (Provegen) Infusion

Immediately stop the infusion, recline the patient onto their back, switch the IV line to normal saline at keep-vein-open (KVO) rate, and administer a 1000-2000 mL normal saline bolus to manage the hypotension. 1

Immediate Actions

Stop the infusion immediately when hypotension occurs (defined as a drop in systolic blood pressure ≥30 mmHg from baseline or systolic BP ≤90 mmHg). 1

Position and IV Access

• Recline the patient onto their back to optimize venous return and cerebral perfusion. 1
• Switch the IV line to normal saline at KVO rate to maintain venous access. 1

Fluid Resuscitation

• Administer a normal saline bolus of 1000-2000 mL for hypotension management. 1
• This addresses the potential volume depletion that often accompanies IV iron reactions, as patients may be volume depleted from pressure natriuresis. 1

Classification and Monitoring

Hypotension toward the end of infusion represents either a moderate or severe hypersensitivity reaction (HSR) depending on accompanying symptoms. 1

Moderate HSR Criteria

• Hypotension (SBP drop ≥30 mmHg or SBP ≤90 mmHg) as an isolated finding or with mild symptoms (transient cough, shortness of breath, tachycardia). 1

Severe/Life-Threatening HSR Criteria

• Hypotension with sudden onset and rapid intensification. 1
• Loss of consciousness. 1
• Involvement of two or more organ systems (cardiovascular, skin, respiratory, gastrointestinal). 1

Monitor vital signs continuously (blood pressure, pulse, respiratory rate, oxygen saturation, temperature) until stable, with observation for at least 15 minutes. 1

Pharmacologic Management

For Moderate HSR with Hypotension

• Consider IV corticosteroid: Hydrocortisone 100-500 mg IV. 1
• Consider IV H2 antagonist: Famotidine 20 mg IV. 1
• Continue normal saline infusion to maintain systolic BP >100 mmHg. 1

For Severe HSR (If Present)

Immediately call emergency services or resuscitation team and treat as anaphylaxis. 1

• Administer epinephrine (1 mg/mL) 0.3 mg IM into the anterolateral mid-third portion of the thigh; may repeat once if needed. 1, 2
• Consider β2 agonist nebulizer (Albuterol 0.083% via nebulizer). 1
• If hypoxemic, provide oxygen by mask or nasal cannula. 1

Critical Pitfall: Avoid Vasopressors and First-Generation Antihistamines

Do not administer vasopressors or first-generation antihistamines (diphenhydramine), as these medications can convert minor infusion reactions into hemodynamically significant serious adverse events, including exacerbation of hypotension, tachycardia, diaphoresis, sedation, and shock. 1, 2

Mechanism of Hypotension

The hypotension represents a hypersensitivity reaction to IV iron, not a true anaphylactic reaction in most cases. 1, 2

• IV iron can trigger complement activation-related pseudoallergy (CARPA), leading to cytokine release and vasodilation. 1, 2
• The reaction typically occurs during or shortly after infusion, though it can manifest toward the end of administration. 1
• Volume depletion may be present due to pressure natriuresis, making patients more susceptible to hypotension. 1

Post-Event Management

If Symptoms Improve

• Monitor for return to baseline and complete resolution of symptoms. 1
• Rechallenge may be considered after discussion with the patient and providing reassurance. 1
• If rechallenge is accepted, restart infusion approximately 15 minutes after complete symptom resolution at 50% of the initial infusion rate. 1
• If well tolerated after 15 minutes, increase slowly; stop immediately if symptoms recur. 1

If Symptoms Do Not Improve

• Continue treatment for individual symptoms and re-evaluate to rule out anaphylaxis. 1
• Seek medical attention if symptoms do not resolve. 1

Patient Education

• Educate the patient on management of delayed reactions (flu-like symptoms, arthralgias, myalgias, fevers) with NSAIDs, which can occur hours to days after infusion. 1, 2, 3
• Symptoms lasting more than 24-48 hours require provider evaluation to rule out other pathologies such as hypophosphatemia. 1

Prevention for Future Infusions

• Slower infusion rates have been associated with lower infusion reaction rates. 1, 2
• Premedication with steroids and antihistamines is not routinely recommended and should be limited to patients with substantial risk factors (multiple drug allergies, prior reaction to IV iron formulation, severe asthma). 1, 2
• Consider alternative IV iron formulations if severe reactions occur. 1, 2