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Dribin TE, Motosue MS, Campbell RL. Overview of Allergy and Anaphylaxis. Immunol Allergy Clin North Am 2023; 43:435-451. [PMID: 37394251 DOI: 10.1016/j.iac.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Allergic reactions and anaphylaxis occur on a severity continuum from mild and self-limited to potentially life-threatening or fatal reactions. Anaphylaxis is typically a multiorgan phenomenon involving a broad range of effector cells and mediators. Emergency department visits for anaphylaxis are increasing, especially among children. There is a broad differential diagnosis for anaphylaxis, and the diagnosis of anaphylaxis can be aided by the use of the National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network clinical diagnostic criteria. Risk factors for severe anaphylaxis include older age, delayed epinephrine administration, and cardiopulmonary comorbidities.
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Affiliation(s)
- Timothy E Dribin
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45229-3039, USA
| | - Megan S Motosue
- Department of Allergy and Immunology, University of Hawaii, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI 96814, USA; Department of Medicine, University of Hawaii, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI 96814, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, 200 First Street Southwest, Generose Building G-410, Rochester, MN, USA.
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2
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Navalpakam A, Thanaputkaiporn N, Poowuttikul P. Anaphylaxis: Long-term management and resources. Allergy Asthma Proc 2023; 44:35-44. [PMID: 36719689 DOI: 10.2500/aap.2023.44.220089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Anaphylaxis is an acute life-threatening event that requires emergent diagnosis and treatment. However, focus on prevention of anaphylaxis is essential in reducing anaphylaxis recurrences and associated mortality. Objective: This literature review was aimed to be a comprehensive resource for practicing allergists in managing anaphylaxis in the long term. We discussed the role of the allergist in the long-term outpatient management of anaphylaxis through identifying risk factors, allergen avoidance, prevention of recurrences, and patient education. Methods: A medical literature search that focused on several areas of long-term management of anaphylaxis was conducted. Results: Patients evaluated by an allergist are more likely to have their anaphylaxis trigger identified, to have their underlying mast cell disorder diagnosed, and to receive desensitization or allergen immunotherapy. Allergists can prevent fatal anaphylaxis by preventing and treating anaphylaxis in patients with ischemic heart disease and by optimally treating patients with comorbid asthma. Allergists can offer specific prevention strategies for allergenic trigger and cofactor avoidance. Education should be focused on patients with a higher risk for recurrence of anaphylaxis, such as those patients with a history of severe symptoms or anaphylaxis, with a peanut and/or tree nut trigger, or with a history of asthma, or female gender. Patient counseling involves providing individualized action plans at each visit and discussing proper use, storage, and safety of epinephrine autoinjectors. Multiple doses of epinephrine need to be prescribed to those who are at risk for severe food-induced, venom immunotherapy-related, or venom-induced anaphylaxis. Wording on medical identification products should be reviewed by the allergist. Anaphylaxis resources for health-care providers are summarized in the article. Conclusion: Ongoing education, providing personalized anaphylaxis action plans, reducing risk factors, and avoiding triggers are key to anaphylaxis prevention and long-term management.
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Abstract
Allergic reactions and anaphylaxis occur on a severity continuum from mild and self-limited to potentially life-threatening or fatal reactions. Anaphylaxis is typically a multiorgan phenomenon involving a broad range of effector cells and mediators. Emergency department visits for anaphylaxis are increasing, especially among children. There is a broad differential diagnosis for anaphylaxis, and the diagnosis of anaphylaxis can be aided by the use of the National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network clinical diagnostic criteria. Risk factors for severe anaphylaxis include older age, delayed epinephrine administration, and cardiopulmonary comorbidities.
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Affiliation(s)
- Timothy E Dribin
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45229-3039, USA
| | - Megan S Motosue
- Department of Allergy and Immunology, University of Hawaii, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI 96814, USA; Department of Medicine, University of Hawaii, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI 96814, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, 200 First Street Southwest, Generose Building G-410, Rochester, MN, USA.
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4
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McGrath FM, Francis A, Fatovich DM, Macdonald SPJ, Arendts G, Bosco A, Woo A, Bosio E. Small nucleolar RNA networks are up-regulated during human anaphylaxis. Clin Exp Allergy 2021; 51:1310-1321. [PMID: 34228845 DOI: 10.1111/cea.13982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anaphylaxis is a severe, potentially life-threatening allergic reaction driven primarily by the activation of mast cells. We still fail to understand factors underlying reaction severity. Furthermore, there is currently no reliable diagnostic test to confirm anaphylaxis in the emergency department (ED). OBJECTIVE This study sought to explore gene expression changes associated with anaphylaxis severity in peripheral blood leucocytes and evaluate biomarker potential. METHODS Microarray analysis (total RNA) was performed using peripheral blood samples from ED patients with moderate (n = 6) or severe (n = 12) anaphylaxis and sepsis (n = 20) at presentation (T0) and one hour later (T1). Results were compared between groups and healthy controls (n = 10 and n = 11 matched to anaphylaxis and sepsis patients, respectively). Changes in gene expression were determined using R programming language, and pathway analysis applied to explore biological processes and pathways associated with genes. Differentially expressed genes were validated in an independent cohort of anaphylaxis (n = 30) and sepsis (n = 20) patients, and healthy controls (n = 10), using quantitative reverse transcription-polymerase chain reaction (qRT-PCR). RESULTS Significant up-regulation of small nucleolar RNAs (snoRNAs) was demonstrated in anaphylaxis compared to sepsis patients in the microarray cohort, at T0 and T1. qRT-PCR analysis of the validation cohort showed five genes: SNORD61, SNORD8, SNORD69, SNORD119 and HIST1H1D to be significantly up-regulated (adjusted p < 0.05) in severe anaphylaxis compared to sepsis. Seven genes (SNORD61, SNORD8, SCARNA21, SNORD69, SNORD110, SNORD119 and SNORD59A) were significantly up-regulated (adjusted p < 0.05) in severe anaphylaxis compared to healthy controls. CONCLUSION This study demonstrates for the first time the unique involvement of snoRNAs in the pathogenesis of anaphylaxis and suggests they are not a general feature of systemic inflammation. Further investigation of snoRNA expression in anaphylaxis could provide insights into disease pathogenesis. CLINICAL RELEVANCE SnoRNAs are up-regulated during acute anaphylaxis in humans and could potentially be used as biomarkers of severe anaphylaxis.
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Affiliation(s)
- Francesca Marina McGrath
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Abbie Francis
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia.,Centre for Child Health Research, The University of Western Australia, Telethon Kids Institute, Nedlands, WA, Australia
| | - Daniel M Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia.,Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA, Australia.,Emergency Department, Royal Perth Hospital, Perth, WA, Australia
| | - Stephen P J Macdonald
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia.,Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA, Australia.,Emergency Department, Royal Perth Hospital, Perth, WA, Australia
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia.,Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA, Australia.,Emergency Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Anthony Bosco
- Centre for Child Health Research, The University of Western Australia, Telethon Kids Institute, Nedlands, WA, Australia
| | - Andrew Woo
- Laboratory for Cancer Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia
| | - Erika Bosio
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia.,Division of Emergency Medicine, Medical School, University of Western Australia, Perth, WA, Australia.,Emergency Department, Royal Perth Hospital, Perth, WA, Australia
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5
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Kelso JM. Anaphylactic reactions to novel mRNA SARS-CoV-2/COVID-19 vaccines. Vaccine 2021; 39:865-867. [PMID: 33441235 PMCID: PMC7837118 DOI: 10.1016/j.vaccine.2020.12.084] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 11/30/2022]
Affiliation(s)
- John M Kelso
- Division of Allergy, Asthma and Immunology, Scripps Clinic, 3811 Valley Centre Drive, San Diego, CA 92130, United States.
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6
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Anaphylaxis Attended in Emergency Departments: a Reliable Picture of Real-world Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00252-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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7
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Management of Patients During Acute Reaction Induced by Drugs. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-00226-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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8
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Su JR, Moro PL, Ng CS, Lewis PW, Said MA, Cano MV. Anaphylaxis after vaccination reported to the Vaccine Adverse Event Reporting System, 1990-2016. J Allergy Clin Immunol 2019; 143:1465-1473. [PMID: 30654049 DOI: 10.1016/j.jaci.2018.12.1003] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 12/07/2018] [Accepted: 12/24/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anaphylaxis, a rare and potentially life-threatening hypersensitivity reaction, can occur after vaccination. OBJECTIVE We sought to describe reports of anaphylaxis after vaccination made to the Vaccine Adverse Event Reporting System (VAERS) during 1990-2016. METHODS We identified domestic reports of anaphylaxis within VAERS using a combination of Medical Dictionary for Regulatory Activity queries and Preferred Terms. We performed a descriptive analysis, including history of hypersensitivity (anaphylaxis, respiratory allergies, and drug allergies) and vaccines given. We reviewed all serious reports and all nonserious reports with available medical records to determine if they met the Brighton Collaboration case definition for anaphylaxis or received a physician's diagnosis. RESULTS During the analytic period, VAERS received 467,960 total reports; 828 met the Brighton Collaboration case definition or received a physician's diagnosis of anaphylaxis: 654 (79%) were classified as serious, and 669 (81%) had medical records available. Of 478 reports in children aged less than 19 years, 65% were male; childhood vaccines were most commonly reported. Of 350 reports in persons aged 19 years or greater, 80% were female, and influenza vaccines were most frequently reported. Overall, 41% of reports described persons with no history of hypersensitivity. We identified 8 deaths, 4 among persons with no history of hypersensitivity. CONCLUSION Anaphylaxis after vaccination is rare in the United States and can occur among persons with no history of hypersensitivity. Most persons recover fully with treatment, but serious complications, including death, can occur.
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Affiliation(s)
- John R Su
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga.
| | - Pedro L Moro
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Carmen S Ng
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Paige W Lewis
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Maria A Said
- Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Md
| | - Maria V Cano
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
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Barni S, Mori F, Giovannini M, de Luca M, Novembre E. In situ simulation in the management of anaphylaxis in a pediatric emergency department. Intern Emerg Med 2019; 14:127-132. [PMID: 29948834 DOI: 10.1007/s11739-018-1891-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 06/06/2018] [Indexed: 12/13/2022]
Abstract
Anaphylaxis is a potentially life-threatening, rapid-onset hypersensitive reaction, usually treated in the emergency department (ED). Failure to recognize anaphylaxis leads to under-treatment with epinephrine and even when correctly diagnosed, epinephrine is not always administered. In addition, often patients who are treated in the ED are not referred for allergy work-up. Simulation is a tool that increases exposure to events in a safe environment, allowing trainers to develop skills without harming patients. The main purpose of our study was to determine whether in situ simulation training increases the frequency of epinephrine use. The secondary aim was to observe whether simulation modifies the number of children investigated over the years before and after the setting up of the simulation training. All patients with anaphylaxis referred to the Pediatric Emergency Department (PED) of the Anna Meyer Children's Hospital from 2004 to 2010 [pre-simulation (PRE-s) period], and from 2011 to 2016 [post-simulation (POST-s) period], were retrospectively included in this observational study. Simulation was carried out using a high-fidelity patient simulator mannequin (SimBaby, Laerdal Medical, Inc, Stavanger, NY). The diagnosis of anaphylaxis was based on the EAACI guidelines. The use of epinephrine significantly increased (p < 0.05) between the PRE-s and POST-s time periods: 2.4% versus 10% patients, respectively. During the two time periods, we also observed a significant increase (p = 0.011) in the number of patients who underwent a complete allergy work-up: 36% versus 51% patients, respectively. According to our results, the in situ simulation program improved the correct management of anaphylaxis in terms of prompt use of epinephrine, and it also led to a higher number of patients being referred to the allergy unit for evaluation.
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Affiliation(s)
- Simona Barni
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy.
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy
| | - Marco de Luca
- Simulation and Risk Management Unit, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Viale Pieraccini, 24, 50134, Florence, Italy
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Kim MY, Park CS, Jeong JW. Management and educational status of adult anaphylaxis patients at emergency department. Korean J Intern Med 2018; 33:1008-1015. [PMID: 29277095 PMCID: PMC6129625 DOI: 10.3904/kjim.2016.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 08/01/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND/AIMS We evaluated the management and educational status of adult anaphylaxis patients at emergency departments (EDs). METHODS Anaphylaxis patients who visited ED from 2011 to 2013 were enrolled from three hospitals. We analyzed clinical features, prior history of anaphylaxis, management and provided education for etiology and/or prevention. For analyzing associated factors with epinephrine injection, Pearson chi-square test was used by SPSS version 21 (IBM Co.). RESULTS A total of 194 anaphylaxis patients were enrolled. Ninety-nine patients (51%) visited ED by themselves. Time interval from symptom onset to ED visit was 62 ± 70.5 minutes. Drug (56.2%) was the most frequent cause of anaphylaxis. Forty-seven patients (24.2%) had prior history of anaphylaxis and 33 patients had same suspicious cause with current anaphylaxis. Cutaneous (88.7%) and respiratory (72.7%) symptoms were frequent. Hypotension was presented in 114 patients (58.8%). Mean observation time in ED was 12 ± 25.7 hours and epinephrine was injected in 114 patients (62%). In 68 patients, epinephrine was injected intramuscularly with mean dose of 0.3 ± 0.10 mg. Associated factor with epinephrine injection was hypotension (p = 0.000). Twenty-three patients (13%) were educated about avoidance of suspicious agent. Epinephrine auto-injectors were prescribed only in five patients. Only 34 (19%) and 72 (40%) patients were consulted to allergist at ED and outpatient allergy department respectively. CONCLUSION We suggested that management and education of anaphylaxis were not fully carried out in ED. An education and promotion program on anaphylaxis is needed for medical staff.
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Affiliation(s)
- Mi-Yeong Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Chan Sun Park
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Jae-won Jeong
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
- Correspondence to Jae-won Jeong, M.D. Department of Internal Medicine, Inje University Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea Tel: +82-31-910-7022 Fax: +82-31-910-7219 E-mail:
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Cohen N, Capua T, Pivko D, Ben-Shoshan M, Benor S, Rimon A. Trends in the diagnosis and management of anaphylaxis in a tertiary care pediatric emergency department. Ann Allergy Asthma Immunol 2018; 121:348-352. [PMID: 29981442 DOI: 10.1016/j.anai.2018.06.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/05/2018] [Accepted: 06/28/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Underdiagnosis of anaphylaxis is a major concern in the pediatric emergency department (PED), leading to failure to administer and prescribe intramuscular epinephrine treatment. OBJECTIVE To examine the clinical features, triggers, and management of anaphylaxis in the PED, with a special focus on the rate of cases diagnosed and treated correctly over time, and to compare correctly diagnosed and misdiagnosed cases. METHODS All records of patients presenting to a tertiary care PED between 2013 and 2016 with a final diagnosis of anaphylaxis or allergic reaction were reviewed. RESULTS The rate of anaphylaxis increased from 0.1% between 2013 and 2014 and 0.24% between 2015 and 2016. Symptoms such as breathing difficulties and wheezing were found significantly less among misdiagnosed patients compared with patients correctly diagnosed with anaphylaxis. Food was the most common causative agent in both of the study periods (88% in 2013-2014 and 91% in 2015-2016), with milk (20% in 2013-2014 and 28% in 2015-2016) and tree nuts (23.1% in 2013-2014 and 23.7% in 2015-2016 as the most prevalent identified triggers. Intramuscular epinephrine treatment in the prehospital and hospital settings and the automatic epinephrine injector prescription rate did not change significantly throughout the study. Referral to an allergist increased from 68% in 2013 to 2014 to 90% in 2015 to 2016. CONCLUSION The rate of visits attributable to anaphylaxis in our PED doubled during the study period, with milk allergy as the most common trigger. Most cases of misdiagnosed and undertreated anaphylaxis had no respiratory signs and symptoms. Novel methods to improve recognition of anaphylaxis and adherence to treatment guidelines are needed.
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Affiliation(s)
- Neta Cohen
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel.
| | - Tali Capua
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Dikla Pivko
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | | | - Shira Benor
- Allergy and Clinical Immunology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ayelet Rimon
- Pediatric Emergency Medicine, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Israel
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Prince BT, Mikhail I, Stukus DR. Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy 2018; 11:143-151. [PMID: 29950873 PMCID: PMC6016581 DOI: 10.2147/jaa.s159400] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Epinephrine is the only effective treatment for anaphylaxis but studies routinely show underutilization. This is especially troubling given the fact that fatal anaphylaxis has been associated with delayed administration of epinephrine. Many potential barriers exist to the proper use of epinephrine during an anaphylactic reaction. This article will explore both patient-and physician-related factors, as well as misconceptions that all contribute to the underuse of epinephrine for the treatment of anaphylaxis.
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Affiliation(s)
- Benjamin T Prince
- Division of Allergy and Immunology, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Irene Mikhail
- Division of Allergy and Immunology, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
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Sacco KA, Gonzalez-Estrada A. An Update on the Management of Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Manmohan M, Müller S, Rauber MM, Koberne F, Reisch H, Koster J, Böhm R, Messelken M, Fischer M, Jakob T. Current state of follow-up care for patients with Hymenoptera venom anaphylaxis in southwest Germany. ALLERGO JOURNAL 2018. [DOI: 10.1007/s15007-018-1523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Anaphylaxis in the Workplace. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Manmohan M, Müller S, Myriam Rauber M, Koberne F, Reisch H, Koster J, Böhm R, Messelken M, Fischer M, Jakob T. Current state of follow-up care for patients with Hymenoptera venom anaphylaxis in southwest Germany: Major impact of early information. ACTA ACUST UNITED AC 2018; 27:4-14. [PMID: 29399436 PMCID: PMC5785614 DOI: 10.1007/s40629-017-0046-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 11/21/2017] [Indexed: 11/17/2022]
Abstract
Background Up to 3.5% of the population experience anaphylactic reactions in response to Hymenoptera stings. Current guidelines are in place for the diagnostic workup and follow-up care of patients with Hymenoptera venom anaphylaxis (HVA). However, little is known about the degree of implementation of the recommendations and patient attitudes toward the recommendations in the general patient population. Methods For the analysis of the follow-up care in real life, a retrospective questionnaire-based study was conducted in unselected patients who had received treatment from an emergency medical response team for HVA, as documented in records of three regional Medical Emergency Response Centers. Results From over 125,000 cases, a filtered list of 1895 patients that coded for anaphylaxis was generated and examination of paper records identified 548 patients with a documented insect sting anaphylaxis. Patients were sent a standardized questionnaire addressing different aspects of diagnostics and follow-up care. Almost 40% of the patients did not receive a referral to an allergist at the emergency center, over 50% did not consult an allergy specialist at any time after the index sting, 25% did not receive any form of diagnostic workup, over 30% did not receive any information about venom immunotherapy (VIT) as treatment option, and only 50% were eventually started on VIT. Emergency medication was prescribed in 90% of the cases, 77% including an adrenalin auto injector, of which 47% were expired at the time of the survey. Patients who were informed about diagnostic and treatment options early during the index event, i. e., during the stay in the emergency department, displayed a higher rate of referral to an allergist (70% vs. 17%), higher rate of diagnostic workup (88% vs. 59%), and a higher rate of initiation of VIT (89% vs. 64%), as compared to patients who did not. Conclusion Our results demonstrate that there are missed opportunities for secondary and tertiary prevention of anaphylaxis due to insect venom allergy and that early information on required diagnostics and treatment options has a major impact on the degree of proper follow-up care in line with current guideline recommendations.
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Affiliation(s)
- Manisha Manmohan
- 1Department of Dermatology, Allergy Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,2Department of Dermatology and Allergology, University Medical Center Giessen, Justus Liebig University, Gaffkystraße 14, 35392 Giessen, Germany.,3Dermatology and Plastic Surgery Institute, Cleveland Clinic, 9500 Euclid Ave., 44195 Cleveland, OH USA
| | - Sabine Müller
- 1Department of Dermatology, Allergy Research Group, Medical Center, University of Freiburg, Freiburg, Germany
| | - Michèle Myriam Rauber
- 2Department of Dermatology and Allergology, University Medical Center Giessen, Justus Liebig University, Gaffkystraße 14, 35392 Giessen, Germany
| | - Frank Koberne
- Emergency Medical Response Center Freiburg, St. Joseph's Hospital, Freiburg, Germany
| | - H Reisch
- Emergency Medical Response Center Freiburg, St. Joseph's Hospital, Freiburg, Germany
| | - Joachim Koster
- 5Emergency Medical Response Center Bad Krozingen, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Richard Böhm
- Department of Anesthesia, Intensive Care and Emergency Medicine, Alb Fils Kliniken GmbH, Klinik am Eichert, Göppingen, Germany
| | - Martin Messelken
- Department of Anesthesia, Intensive Care and Emergency Medicine, Alb Fils Kliniken GmbH, Klinik am Eichert, Göppingen, Germany
| | - Matthias Fischer
- Department of Anesthesia, Intensive Care and Emergency Medicine, Alb Fils Kliniken GmbH, Klinik am Eichert, Göppingen, Germany
| | - Thilo Jakob
- 1Department of Dermatology, Allergy Research Group, Medical Center, University of Freiburg, Freiburg, Germany.,2Department of Dermatology and Allergology, University Medical Center Giessen, Justus Liebig University, Gaffkystraße 14, 35392 Giessen, Germany
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Alvarez-Perea A, Tanno LK, Baeza ML. How to manage anaphylaxis in primary care. Clin Transl Allergy 2017; 7:45. [PMID: 29238519 PMCID: PMC5724339 DOI: 10.1186/s13601-017-0182-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/16/2017] [Indexed: 12/13/2022] Open
Abstract
Anaphylaxis is defined as a severe life-threatening generalized or systemic hypersensitivity reaction characterized by rapidly developing airway and/or circulation problems. It presents with very different combinations of symptoms and apparently mild signs and can progress to fatal anaphylactic shock unpredictably. The difficulty in recognizing anaphylaxis is due, in part, to the variability of diagnostic criteria, which in turn leads to a delay in administration of appropriate treatment, thus increasing the risk of death. The use of validated clinical criteria can facilitate the diagnosis of anaphylaxis. Intramuscular epinephrine (adrenaline) is the medication of choice for the emergency treatment of anaphylaxis. Administration of corticosteroids and H1-antihistamines should not delay the administration of epinephrine, and the management of a patient with anaphylaxis should not end with the acute episode. Long-term management of anaphylaxis should include avoidance of triggers, following confirmation by an allergology study. Etiologic factors suspected in the emergency department often differ from the real causes of anaphylaxis. Evaluation of patients with a history of anaphylaxis should also include an assessment of personal data, such as age and comorbidities, which may increase the risk of severe reactions. Special attention should also be paid to co-factors, as these may easily confound the cause of the anaphylaxis. Patients experiencing anaphylaxis should administer epinephrine as soon as possible. Education (including the use of Internet and social media), written personalized emergency action plans, and self-injectable epinephrine have proven useful for the treatment of further anaphylaxis episodes.
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Affiliation(s)
- Alberto Alvarez-Perea
- Allergy Service, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46, 28007 Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Luciana Kase Tanno
- Hospital Sírio Libanês, São Paulo, Brazil
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, Montpellier, France
- Pierre and Marie Curie Institute of Epidemiology and Public Health, Sorbonne Universités, Paris, France
| | - María L. Baeza
- Allergy Service, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo, 46, 28007 Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain
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Motosue MS, Bellolio MF, Van Houten HK, Shah ND, Campbell RL. Risk factors for severe anaphylaxis in the United States. Ann Allergy Asthma Immunol 2017; 119:356-361.e2. [DOI: 10.1016/j.anai.2017.07.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/06/2017] [Accepted: 07/11/2017] [Indexed: 01/17/2023]
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Predictors of epinephrine dispensing and allergy follow-up after emergency department visit for anaphylaxis. Ann Allergy Asthma Immunol 2017; 119:452-458.e1. [PMID: 28916424 DOI: 10.1016/j.anai.2017.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 08/04/2017] [Accepted: 08/08/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND National guidelines recommend that patients with anaphylaxis be prescribed an epinephrine auto-injector (EAI) and referred to an allergy/immunology (A/I) specialist. OBJECTIVE To evaluate guideline concordance and identify predictors of EAI dispensing and A/I follow-up in patients with anaphylaxis treated in the emergency department (ED). METHODS We identified patients seen in the ED for anaphylaxis from 2010 through 2014 from an administrative claims database using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. RESULTS Of 7,790 patients identified, 46.5% had an EAI dispensed and 28.8% had A/I follow-up within 1 year after discharge. On multivariable analysis, those 65 years or older (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.30-0.41) and with a medication trigger (OR 0.24, 95% CI 0.21-0.28) had a lower likelihood of EAI dispensing. Those younger than 5 years (OR 2.67, 95% CI 2.15-3.32) and with food (OR 1.40, 95% CI 1.24-1.59) or venom (OR 4.48, 95% CI 3.51-5.72) triggers had a higher likelihood of EAI dispensing. Similarly, for A/I follow-up, the likelihood was lower for age 65 years or older (OR 0.46, 95% CI 0.39-0.54) and medication trigger (OR 0.66, 95% CI 0.56-0.78) and higher for age younger than 5 years (OR 3.15, 95% CI 2.63-3.77) and food trigger (OR 1.39, 95% CI 1.22-1.58). CONCLUSION Overall, 46.5% of patients with anaphylaxis in the ED had EAI dispensing and 28.8% had A/I follow-up. Patient age and triggers were associated with likelihood of EAI dispensing and A/I follow-up. Post-ED visit anaphylaxis management can be improved, with the potential to decrease future morbidity and mortality risk.
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Motosue MS, Bellolio MF, Van Houten HK, Shah ND, Bellamkonda VR, Nestler DM, Campbell RL. Temporal Trends in Epinephrine Dispensing and Allergy/Immunology Follow-up Among Emergency Department Anaphylaxis Patients in the United States, 2005-2014. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1272-1279.e1. [DOI: 10.1016/j.jaip.2017.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/31/2017] [Accepted: 06/14/2017] [Indexed: 11/29/2022]
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Further Evaluation of Factors That May Predict Biphasic Reactions in Emergency Department Anaphylaxis Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1295-1301. [DOI: 10.1016/j.jaip.2017.07.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 11/21/2022]
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Robinson M, Greenhawt M, Stukus DR. Factors associated with epinephrine administration for anaphylaxis in children before arrival to the emergency department. Ann Allergy Asthma Immunol 2017; 119:164-169. [PMID: 28711194 DOI: 10.1016/j.anai.2017.06.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/15/2017] [Accepted: 06/02/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Epinephrine is the first-line treatment for anaphylaxis but may be underused by patients and medical personnel. OBJECTIVE To evaluate factors associated with anaphylaxis management before arrival at the emergency department (ED) or urgent care center (UCC). METHODS We performed a retrospective review of electronic medical records for all patients aged 0 to 25 years presenting with anaphylaxis to the ED or UCC at a pediatric academic referral center during 2009 to 2013. RESULTS A total of 408 patients (mean age, 7.25 years; 62% male) were included for analysis. Only 148 patients (36.3%) received epinephrine before arrival at the ED or UCC. Reactions occurring at home (n = 36/114) were less likely to be treated with epinephrine compared with reactions occurring at school (n = 30/49) (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.15-0.59). The odds of receiving epinephrine before arrival at the ED or UCC were significantly lower with a 2-organ system (OR, 0.50; 95% CI, 0.30-0.85) or 3-organ system (OR, 0.41; 95% CI, 0.21-0.81) presentation compared with 1-organ system involvement. Foods (342 [83.8%]) were the most commonly reported provoking trigger. Patients who did not receive epinephrine before arrival at the ED or UCC were significantly less likely to be discharged to home (OR, 0.56; 95% CI, 0.37-0.86; P = .01). CONCLUSION This study identifies factors associated with prehospital management of anaphylaxis for children, which highlight that epinephrine administration may be occurring with considerable delay. Increased awareness and education of caregivers, patients, and medical professionals are necessary to provide optimal management.
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Affiliation(s)
- Melissa Robinson
- Section of Allergy and Immunology, National Jewish Hospital, Denver, Colorado
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital of Colorado, University of Colorado Denver School of Medicine, Denver, Colorado
| | - David R Stukus
- Department of Pediatrics, Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio.
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Thomson H, Seith R, Craig S. Inaccurate diagnosis of paediatric anaphylaxis in three Australian Emergency Departments. J Paediatr Child Health 2017; 53:698-704. [PMID: 28670809 DOI: 10.1111/jpc.13483] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/30/2016] [Accepted: 12/04/2016] [Indexed: 01/28/2023]
Abstract
AIM To determine the accuracy of emergency department (ED) paediatric anaphylaxis diagnosis, and to identify factors associated with misdiagnosis. METHODS Retrospective chart review of children aged 0-18 years with allergic presentations to three Victorian EDs in 2014. Cases were included if an ED diagnosis of anaphylaxis was recorded, or the presentation met international consensus criteria for anaphylaxis. RESULTS Of the 60 143 paediatric ED presentations during the study period, 1551 allergy-related presentations were identified and reviewed. One hundred and eighty-seven met consensus criteria for anaphylaxis, and another 24 were diagnosed with anaphylaxis without meeting criteria. Of the 211 presentations, 105 cases were given an ED diagnosis of anaphylaxis and 106 cases were given an alternative diagnosis in ED. ED assessment had a sensitivity of 43.2% (95% confidence interval (CI) 36.1-50.7%) and specificity of 97.9% (95% CI 96.9-98.7%) for anaphylaxis. Multiple logistic regression demonstrated that an ED anaphylaxis diagnosis was associated with previous anaphylaxis (odds ratio (OR) 3.20; 95% CI 1.52-6.75), arrival by ambulance (OR 2.80; 95% CI 1.36-5.74), a high-acuity triage category (OR 4.51; 95% CI 2.20-9.25) and presentation to a tertiary hospital (OR 2.86; 95% CI 1.44-5.67). ED diagnosis of anaphylaxis was less likely in those with resolution of symptoms and signs in at least one organ system prior to arrival (OR 0.27; 95% CI 0.12-0.62). CONCLUSION In children with allergic presentations, ED assessment has a low sensitivity but high specificity for anaphylaxis. Attention to resolved pre-hospital symptoms and awareness of diagnostic criteria are important considerations for accurate ED diagnosis of anaphylaxis.
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Affiliation(s)
- Hector Thomson
- School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia
| | - Robert Seith
- School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia.,Paediatric Emergency Department, Monash Children's Hospital, Victoria, Australia
| | - Simon Craig
- School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia.,Paediatric Emergency Department, Monash Children's Hospital, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Takazawa T, Oshima K, Saito S. Drug-induced anaphylaxis in the emergency room. Acute Med Surg 2017; 4:235-245. [PMID: 29123869 PMCID: PMC5674474 DOI: 10.1002/ams2.282] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/22/2017] [Indexed: 12/16/2022] Open
Abstract
Anaphylaxis is a life‐threatening, systemic allergic reaction that presents unique challenges for emergency care practitioners. Anaphylaxis occurs more frequently than previously believed. Therefore, proper knowledge regarding the epidemiology, mechanisms, symptoms, diagnosis, and treatment of anaphylaxis is essential. In particular, the initial treatment strategy, followed by correct diagnosis, in the emergency room is critical for preventing fatal anaphylaxis, although making a diagnosis is not easy because of the broad and often atypical presentation of anaphylaxis. To this end, the clinical criteria proposed by the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network are useful, which, together with a differential diagnosis, could enable a more accurate diagnosis. Additional in vitro tests, such as plasma histamine and tryptase measurements, are also helpful. It should be emphasized that adrenaline is the only drug recommended as first‐line therapy in all published national anaphylaxis guidelines. Most international anaphylaxis guidelines recommend injecting adrenaline by the intramuscular route in the mid‐anterolateral thigh, whereas i.v. adrenaline is an option for patients with severe hypotension or cardiac arrest unresponsive to intramuscular adrenaline and fluid resuscitation. In addition to the route of administration, choosing the appropriate dose of adrenaline is essential, because serious adverse effects can potentially occur after an overdose of adrenaline. Furthermore, to avoid future recurrence of anaphylaxis, providing adrenaline auto‐injectors and making an etiological diagnosis, including confirmation of the offending trigger, are recommended for patients at risk of anaphylaxis before their discharge from the emergency room.
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Affiliation(s)
| | - Kiyohiro Oshima
- Department of Emergency Medicine Gunma University Graduate School of Medicine Maebashi Gunma Japan
| | - Shigeru Saito
- Department of Anesthesiology Gunma University Graduate School of Medicine Maebashi Gunma Japan
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Rueter K, Ta B, Bear N, Lucas M, Prescott S. Physician training programs significantly improve diagnosis in cases coded as anaphylaxis over time: A major factor compounding time-trend data? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:858-860. [DOI: 10.1016/j.jaip.2016.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 09/07/2016] [Accepted: 10/03/2016] [Indexed: 11/29/2022]
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Alvarez-Perea A, Ameiro B, Morales C, Zambrano G, Rodríguez A, Guzmán M, Zubeldia JM, Baeza ML. Anaphylaxis in the Pediatric Emergency Department: Analysis of 133 Cases After an Allergy Workup. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1256-1263. [PMID: 28389303 DOI: 10.1016/j.jaip.2017.02.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/11/2017] [Accepted: 02/17/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Data on the incidence and characteristics of pediatric anaphylaxis are scarce. Reported causes of anaphylaxis are mostly those suspected by the physician in the emergency department (ED), which may not coincide with the real triggers. OBJECTIVES To investigate the incidence, management, and etiology of pediatric anaphylaxis in the ED of a Spanish tertiary hospital and to determine the concordance between the suspected etiology in the ED and diagnosis after the allergy workup. METHODS We performed an observational, descriptive study of all patients with anaphylaxis attended in the pediatric ED from 2012 to 2014. Cases were considered anaphylaxis based on National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network criteria. We recorded data on clinical characteristics, management, etiology suspected by the ED physician and patient (or relatives), and the workup performed in the allergy department. RESULTS We recorded 133 cases of anaphylaxis (incidence, 0.12%), with 20 cases (15%) recorded in children younger than 12 months. Anaphylaxis was correctly diagnosed in the ED in 70 cases (53%). Food allergy was the cause of anaphylaxis in 106 out of 118 studied in the allergy department (AD) (90%). The final etiology differed from the etiology initially suspected in the ED in 42 cases (39%). After the study, the frequency of patients with unidentified triggers decreased by 75%. CONCLUSIONS The incidence of anaphylaxis is higher in children than previously reported in adults from the same center, and food is the trigger in most cases. To prevent erroneous diagnoses, the etiology of anaphylaxis should be established after an appropriate workup.
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Affiliation(s)
- Alberto Alvarez-Perea
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain.
| | - Beatriz Ameiro
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Cristina Morales
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Gabriela Zambrano
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana Rodríguez
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel Guzmán
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - José Manuel Zubeldia
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain
| | - María L Baeza
- Allergy Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute, Madrid, Spain; Biomedical Research Network on Rare Diseases (CIBERER)-U761, Madrid, Spain
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Abstract
Anaphylaxis is a severe, generalized allergic or hypersensitivity reaction that is rapid in onset and may cause death. Epinephrine (adrenaline) can be life-saving when administered as rapidly as possible once anaphylaxis is recognized. This clinical report from the American Academy of Pediatrics is an update of the 2007 clinical report on this topic. It provides information to help clinicians identify patients at risk of anaphylaxis and new information about epinephrine and epinephrine autoinjectors (EAs). The report also highlights the importance of patient and family education about the recognition and management of anaphylaxis in the community. Key points emphasized include the following: (1) validated clinical criteria are available to facilitate prompt diagnosis of anaphylaxis; (2) prompt intramuscular epinephrine injection in the mid-outer thigh reduces hospitalizations, morbidity, and mortality; (3) prescribing EAs facilitates timely epinephrine injection in community settings for patients with a history of anaphylaxis and, if specific circumstances warrant, for some high-risk patients who have not previously experienced anaphylaxis; (4) prescribing epinephrine for infants and young children weighing <15 kg, especially those who weigh 7.5 kg and under, currently presents a dilemma, because the lowest dose available in EAs, 0.15 mg, is a high dose for many infants and some young children; (5) effective management of anaphylaxis in the community requires a comprehensive approach involving children, families, preschools, schools, camps, and sports organizations; and (6) prevention of anaphylaxis recurrences involves confirmation of the trigger, discussion of specific allergen avoidance, allergen immunotherapy (eg, with stinging insect venom, if relevant), and a written, personalized anaphylaxis emergency action plan; and (7) the management of anaphylaxis also involves education of children and supervising adults about anaphylaxis recognition and first-aid treatment.
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Affiliation(s)
- Scott H Sicherer
- Professor of Pediatrics, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - F Estelle R Simons
- Department of Pediatrics & Child Health, and Department of Immunology, College of Medicine, Faculty of Health Sciences, The University of Manitoba, Winnipeg, Canada
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Hemler JA, Sharma HP. Management of children with anaphylaxis in an urban emergency department. Ann Allergy Asthma Immunol 2017; 118:381-383. [PMID: 28132736 DOI: 10.1016/j.anai.2016.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Jonathan A Hemler
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Hemant P Sharma
- Division of Allergy and Immunology, Children's National Medical Center, Washington, DC
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Prospective Validation of the NIAID/FAAN Criteria for Emergency Department Diagnosis of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:1220-1226. [DOI: 10.1016/j.jaip.2016.06.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/23/2016] [Accepted: 06/02/2016] [Indexed: 11/22/2022]
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Rostaher A, Hofer-Inteeworn N, Kümmerle-Fraune C, Fischer NM, Favrot C. Triggers, risk factors and clinico-pathological features of urticaria in dogs - a prospective observational study of 24 cases. Vet Dermatol 2016; 28:38-e9. [DOI: 10.1111/vde.12342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Ana Rostaher
- Clinic for Small Animal Internal Medicine; Dermatology unit; Vetsuisse Faculty University of Zurich; Winterthurerstrasse 260 8057 Zurich Switzerland
| | - Natalie Hofer-Inteeworn
- Clinic for Small Animal Internal Medicine; Vetsuisse Faculty University of Zurich; Winterthurerstrasse 260 8057 Zurich Switzerland
| | - Claudia Kümmerle-Fraune
- Clinic for Small Animal Internal Medicine; Vetsuisse Faculty University of Zurich; Winterthurerstrasse 260 8057 Zurich Switzerland
| | - Nina Maria Fischer
- Clinic for Small Animal Internal Medicine; Dermatology unit; Vetsuisse Faculty University of Zurich; Winterthurerstrasse 260 8057 Zurich Switzerland
| | - Claude Favrot
- Clinic for Small Animal Internal Medicine; Dermatology unit; Vetsuisse Faculty University of Zurich; Winterthurerstrasse 260 8057 Zurich Switzerland
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31
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Badellino H, Jares E. Advances in Food-Induced Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0093-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McNeil MM, Weintraub ES, Duffy J, Sukumaran L, Jacobsen SJ, Klein NP, Hambidge SJ, Lee GM, Jackson LA, Irving SA, King JP, Kharbanda EO, Bednarczyk RA, DeStefano F. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol 2016; 137:868-78. [PMID: 26452420 PMCID: PMC4783279 DOI: 10.1016/j.jaci.2015.07.048] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/31/2015] [Accepted: 07/31/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Anaphylaxis is a potentially life-threatening allergic reaction. The risk of anaphylaxis after vaccination has not been well described in adults or with newer vaccines in children. OBJECTIVE We sought to estimate the incidence of anaphylaxis after vaccines and describe the demographic and clinical characteristics of confirmed cases of anaphylaxis. METHODS Using health care data from the Vaccine Safety Datalink, we determined rates of anaphylaxis after vaccination in children and adults. We first identified all patients with a vaccination record from January 2009 through December 2011 and used diagnostic and procedure codes to identify potential anaphylaxis cases. Medical records of potential cases were reviewed. Confirmed cases met the Brighton Collaboration definition for anaphylaxis and had to be determined to be vaccine triggered. We calculated the incidence of anaphylaxis after all vaccines combined and for selected individual vaccines. RESULTS We identified 33 confirmed vaccine-triggered anaphylaxis cases that occurred after 25,173,965 vaccine doses. The rate of anaphylaxis was 1.31 (95% CI, 0.90-1.84) per million vaccine doses. The incidence did not vary significantly by age, and there was a nonsignificant female predominance. Vaccine-specific rates included 1.35 (95% CI, 0.65-2.47) per million doses for inactivated trivalent influenza vaccine (10 cases, 7,434,628 doses given alone) and 1.83 (95% CI, 0.22-6.63) per million doses for inactivated monovalent influenza vaccine (2 cases, 1,090,279 doses given alone). The onset of symptoms among cases was within 30 minutes (8 cases), 30 to less than 120 minutes (8 cases), 2 to less than 4 hours (10 cases), 4 to 8 hours (2 cases), the next day (1 case), and not documented (4 cases). CONCLUSION Anaphylaxis after vaccination is rare in all age groups. Despite its rarity, anaphylaxis is a potentially life-threatening medical emergency that vaccine providers need to be prepared to treat.
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Affiliation(s)
- Michael M McNeil
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga.
| | - Eric S Weintraub
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Jonathan Duffy
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
| | - Lakshmi Sukumaran
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
| | | | | | | | - Grace M Lee
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Health Care Institute, Boston, Mass
| | | | | | | | - Elyse O Kharbanda
- HealthPartners Institute for Education and Research, Minneapolis, Minn
| | - Robert A Bednarczyk
- Kaiser Permanente Center for Health Research, and the Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Frank DeStefano
- Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga
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Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, Ellis A, Golden DBK, Greenberger P, Kemp S, Khan D, Ledford D, Lieberman J, Metcalfe D, Nowak-Wegrzyn A, Sicherer S, Wallace D, Blessing-Moore J, Lang D, Portnoy JM, Schuller D, Spector S, Tilles SA. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol 2016; 115:341-84. [PMID: 26505932 DOI: 10.1016/j.anai.2015.07.019] [Citation(s) in RCA: 299] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/12/2015] [Indexed: 12/12/2022]
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Simons FER, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF, El-Gamal YM, Brown SG, Park HS, Sheikh A. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organ J 2015; 8:32. [PMID: 26525001 PMCID: PMC4625730 DOI: 10.1186/s40413-015-0080-1] [Citation(s) in RCA: 317] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/25/2015] [Indexed: 11/10/2022] Open
Abstract
The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis provide a unique global perspective on this increasingly common, potentially life-threatening disease. Recommendations made in the original WAO Anaphylaxis Guidelines remain clinically valid and relevant, and are a widely accessed and frequently cited resource. In this 2015 update of the evidence supporting recommendations in the Guidelines, new information based on anaphylaxis publications from January 2014 through mid- 2015 is summarized. Advances in epidemiology, diagnosis, and management in healthcare and community settings are highlighted. Additionally, new information about patient factors that increase the risk of severe and/or fatal anaphylaxis and patient co-factors that amplify anaphylactic episodes is presented and new information about anaphylaxis triggers and confirmation of triggers to facilitate specific trigger avoidance and immunomodulation is reviewed. The update includes tables summarizing important advances in anaphylaxis research.
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Affiliation(s)
- F Estelle R Simons
- Department of Pediatrics & Child Health and Department of Immunology, College of Medicine, Faculty of Health Sciences, The University of Manitoba, Room FE125, 820 Sherbrook Street, Winnipeg, R3A 1R9 MB Canada
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy & Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa Japan
| | - Mario Sanchez-Borges
- Allergy and Clinical Immunology Department, Centro Medico-Docente La Trinidad, Caracas, Venezuela
| | - Bernard Y Thong
- Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Margitta Worm
- Allergie-Centrum-Charite, Klinik fur Dermatologie, Venerologie und Allergologie, Campus Charite Mitte, Universitatsmedizin, Berlin, Germany
| | - Luciana Kase Tanno
- Department of Allergy and Clinical Immunology, Hospital Servidor Publico Estadual de Sao Paulo and Hospital Sirio-Libanes, Sao Paulo, Brazil
| | | | - Yehia M El-Gamal
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Simon Ga Brown
- Royal Hobart Hospital, Tasmania, and University of Western Australia and Royal Perth Hospital, Perth, Western Australia
| | - Hae-Sim Park
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Seoul, South Korea
| | - Aziz Sheikh
- Allergy & Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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Addressing barriers to emergency anaphylaxis care: from emergency medical services to emergency department to outpatient follow-up. Ann Allergy Asthma Immunol 2015; 115:301-5. [PMID: 26256577 DOI: 10.1016/j.anai.2015.07.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/29/2015] [Accepted: 07/08/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Anaphylaxis is a systemic life-threatening allergic reaction that presents unique challenges for emergency care practitioners. Allergists and emergency physicians have a history of collaborating to promote an evidence-based, multidisciplinary approach to improve the emergency management and follow-up of patients with or at risk of anaphylaxis. OBJECTIVES To review recent scientific literature about anaphylaxis, discuss barriers to care, and recommend strategies to support improvement in emergency anaphylaxis care. METHODS An expert panel of allergists and emergency physicians was convened by the American College of Allergy, Asthma and Immunology in November 2014 to discuss current knowledge about anaphylaxis, identify opportunities for emergency practitioners and allergists to partner to address barriers to care, and recommend strategies to improve medical management of anaphylaxis along the continuum of care: from emergency medical systems and emergency department practitioners for acute management through appropriate outpatient follow-up with allergists to confirm diagnosis, identify triggers, and plan long-term care. RESULTS The panel identified key barriers to anaphylaxis care, including difficulties in making an accurate diagnosis, low rates of epinephrine administration during acute management, and inadequate follow-up. Strategies to overcome these barriers were discussed and recommendations made for future allergist/emergency physician collaborations, and key messages to be communicated to emergency practitioners were proposed. CONCLUSION The panel recommended that allergists and emergency physicians continue to work in partnership, that allergists be proactive in outreach to emergency care practitioners, and that easy-to-access educational programs and materials be developed for use by emergency medical systems and emergency department practitioners in the training environment and in practice.
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