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Gudichsen JH, Bækdal EA, Jessen FB, Lassen AT, Bindslev-Jensen C, Mortz CG, Mikkelsen S. Anaphylaxis: first clinical presentation, subsequent referral practise, and suspected elicitor-an observational study. Intern Emerg Med 2024; 19:2047-2056. [PMID: 38598086 PMCID: PMC11467102 DOI: 10.1007/s11739-024-03589-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/19/2024] [Indexed: 04/11/2024]
Abstract
Anaphylaxis is an allergic manifestation characterised by rapid onset and progression. Rapid treatment may be challenging in patients with atypical symptoms or no previous history of anaphylaxis. This study aimed to describe the clinical prehospital presentation of first-time anaphylactic patients. To help target educational initiatives, we sought to identify which groups of medical professionals are most likely to encounter first-time anaphylactic patients and investigated the referral pattern for suspected anaphylactic patients for specialised treatment. A retrospective register-based study from the Region of Southern Denmark. Patients referred to the Allergy Centre, Odense University Hospital, from 2019 to 2021 were included. The medical records were manually reviewed for first contact with the emergency departments or the emergency medical service. 444 patients with suspected anaphylaxis were referred. 226 patients had grade 3-5 systemic allergic reactions as classified by the World Allergy Organisation; 90% had cutaneous symptoms, 63% symptoms from the central nervous system, 42% gastrointestinal symptoms, 40% cardiovascular symptoms, 36% had upper-airway symptoms, and 36% had lower-airway symptoms. Patients treated prehospitally had a significantly more severe degree of anaphylaxis than patients only treated within the hospital. More than half of the patients with suspected anaphylaxis were referred to the Allergy Centre from the emergency departments. Patients with allergies progressing to severe anaphylaxis most often are treated prehospitally before transport to emergency departments. From the emergency departments, they are referred to the allergy centre. Education concerning the immediate treatment of severe anaphylaxis should primarily be targeted towards prehospital care providers.
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Affiliation(s)
- Julie Holst Gudichsen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Kløvervænget 15, 5000, Odense C, Denmark
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense C, Denmark
| | - Emil Aggerholm Bækdal
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Kløvervænget 15, 5000, Odense C, Denmark
| | - Frederik Bloch Jessen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Kløvervænget 15, 5000, Odense C, Denmark
| | - Annmarie Touborg Lassen
- Emergency Medicine Research Unit, University of Southern Denmark and Odense University Hospital, Odense C, Denmark
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Kløvervænget 15, 5000, Odense C, Denmark
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Kløvervænget 15, 5000, Odense C, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense C, Denmark.
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Holst Gudichsen J, Aggerholm Bækdal E, Mikkelsen S, Touborg Lassen A, Bloch Jessen F, Bindslev-Jensen C, Mortz CG. Prehospital and In-Hospital Treatment with Adrenaline and Related Prognosis in Anaphylaxis Patients. Int Arch Allergy Immunol 2024; 185:678-687. [PMID: 38467120 DOI: 10.1159/000536315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/10/2024] [Indexed: 03/13/2024] Open
Abstract
INTRODUCTION Although intramuscular adrenaline is the recommended first-line treatment for anaphylaxis, not all patients receive this treatment. The consequences in daily clinical practice are sparsely described. This study aimed to investigate the treatment administered to anaphylactic patients and the related prognosis. METHODS A retrospective register-based study of patients with anaphylaxis referred to the allergy centre, Odense University Hospital (2019-2021). Each patient's medical records were reviewed for contacts with the emergency departments and the prehospital emergency medical service in the Region of Southern Denmark. The World Allergy Organization (WAO) grading system was used to assess the severity of prehospital and in-hospital anaphylaxis. Furthermore, the treatment administered to the patients was registered. RESULTS In total, 315 patients were included. The prehospital system had contact with 256 of these patients (two were released prehospitally following treatment and 12 patients had insufficient data to assess anaphylaxis). Of the remaining 242 patients, 115 had anaphylaxis prehospitally (WAO grades 3-5); 59% (67/115) received adrenaline. Among the 67 patients who received prehospital adrenaline, 9 patients (13.4%; 95% CI: 6.3-24.0%) still had anaphylaxis at arrival at the emergency department. Of the 48 patients that were not treated with prehospital adrenaline, 17 patients (35.5%; 95% CI: 22.1-50.5) had anaphylaxis at the arrival to the emergency department. Among the 127 patients without prehospital anaphylaxis (WAO grades 0-2), 22 patients (18.2%; 95% CI: 11.8-26.2%) who did not receive prehospital adrenaline had anaphylaxis at arrival to the emergency department, while none of the 6 patients treated prehospitally with adrenaline had anaphylaxis. CONCLUSION Omission of prehospital adrenaline in anaphylactic patients is associated with more severe anaphylactic symptoms at arrival to the hospital. Adrenaline treatment remains suboptimal since only half of the patients received prehospital adrenaline and only 1 out of 4 patients, with clinical signs of anaphylaxis, received adrenaline inside the hospital.
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Affiliation(s)
- Julie Holst Gudichsen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Odense, Denmark,
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark,
| | - Emil Aggerholm Bækdal
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Annmarie Touborg Lassen
- Emergency Medicine Research Unit, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Frederik Bloch Jessen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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Alqurashi W, Shaker M, Wells GA, Collins GS, Greenhawt M, Curran JA, Zemek R, Schuh S, Ellis A, Gerdts J, Kreviazuk C, Dixon A, Eltorki M, Freedman SB, Gravel J, Poonai N, Worm M, Plint AC. Canadian Anaphylaxis Network-Predicting Recurrence after Emergency Presentation for Allergic REaction (CAN-PREPARE): a prospective, cohort study protocol. BMJ Open 2022; 12:e061976. [PMID: 36316072 PMCID: PMC9628530 DOI: 10.1136/bmjopen-2022-061976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 10/09/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Anaphylaxis is a severe, potentially fatal multiorgan system manifestation of an allergic reaction. The highest incidence of anaphylaxis is in children and adolescents. Biphasic anaphylaxis (BA) is defined as the recurrence of allergic symptoms after resolution of an initial reaction. It has been reported to occur in 10%-20% of cases within 1-48 hours from the onset of the initial reaction. The dilemma for physicians is determining which patients with resolved anaphylaxis should be observed for BA and for how long. Guidelines for duration of postanaphylaxis monitoring vary, are based on limited evidence and can have unintended negative impacts on patient safety, quality of life and healthcare resources. The objectives of this study are to derive a prognostic model for BA and to develop a risk-scoring system that informs disposition decisions of children who present to emergency departments (ED) with anaphylaxis. METHODS AND ANALYSIS This prospective multicentre cohort study will enrol 1682 patients from seven paediatric EDs that are members of the Paediatric Emergency Research Canada network. We will enrol patients younger than 18 years of age with an allergic reaction meeting anaphylaxis diagnostic criteria. Trained ED research assistants will screen, obtain consent and prospectively collect study data. Research assistants will follow patients during their ED visit and ascertain, in conjunction with the medical team, if the patient develops BA. A standardised follow-up survey conducted following study enrolment will determine if a biphasic reaction occurred after ED disposition. Model development will conform to the broad principles of the PROGRESS (Prognosis Research Strategy) framework and reporting will follow the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis Statement. ETHICS AND DISSEMINATION Ethics approval has been received from all participating centres. Our dissemination plan focuses on informing clinicians, policy makers and parents of the results through publication in peer-reviewed journals and broadcasting on multiple media platforms. TRIAL REGISTRATION NUMBER NCT05135377.
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Affiliation(s)
- Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Marcus Shaker
- Section of Allergy and Clinical Immunology, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire, USA
| | - George A Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Gary Stephen Collins
- Centre for Statistics in Medicine, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, UK
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Janet A Curran
- Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Suzanne Schuh
- Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anne Ellis
- Division of Allergy and Immunology, Queen's University, Kingston, Ontario, Canada
| | | | - Cheryl Kreviazuk
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Andrew Dixon
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Stephen B Freedman
- Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jocelyn Gravel
- Centre Hospitalier Universitaire Sainte-Justine, Universite de Montreal, Montreal, Québec, Canada
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology and Allergy, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Amy C Plint
- Department of Pediatrics and Emergency Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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Patel N, Chong KW, Yip AYG, Ierodiakonou D, Bartra J, Boyle RJ, Turner PJ. Use of multiple epinephrine doses in anaphylaxis: A systematic review and meta-analysis. J Allergy Clin Immunol 2021; 148:1307-1315. [PMID: 33862009 PMCID: PMC8588837 DOI: 10.1016/j.jaci.2021.03.042] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/25/2021] [Accepted: 03/24/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Regulatory bodies recommend that all patients at risk of anaphylaxis be prescribed 2 epinephrine autoinjectors, which they should carry at all times. This is in contrast to some guidelines. The proportion of anaphylaxis reactions that are treated with multiple doses of epinephrine has not been systematically evaluated. OBJECTIVE Our aim was to undertake a systematic review and meta-analysis of published studies reporting epinephrine treatment for anaphylaxis in which data relating to the number of doses administered were available. METHODS We searched the Medline, Embase, and Cochrane databases for relevant studies reporting at least 10 anaphylaxis events (due to food or venom) from 1946 until January 2020. Data were extracted in duplicate for the meta-analysis, and the risk of bias was assessed. The study was registered under the PROSPERO identifier CRD42017069109. RESULTS A total of 86 studies (36,557 anaphylaxis events) met the inclusion criteria (20 of the studies [23%] were prospective studies; 64 [74%] reported reactions in the community, and 22 [26%] included food challenge data). Risk of bias was assessed as low in 50 studies. Overall, 7.7% of anaphylaxis events from any cause (95% CI = 6.4-9.1) were treated with multiple doses of epinephrine. When only epinephrine-treated reactions for which subsequent doses were administered by a health care professional were considered, 11.1% of food-induced reactions (95% CI = 9.4-13.2) and 17.1% of venom-induced reactions (95% CI = 11.3-25.0) were treated with more than 1 epinephrine dose. Heterogeneity was moderate to high in the meta-analyses, but at sensitivity analysis this estimate was not affected by study design or anaphylaxis definition. CONCLUSION Around 1 in 10 anaphylaxis reactions are treated with more than 1 dose of epinephrine.
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Affiliation(s)
- Nandinee Patel
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Kok Wee Chong
- Allergy Service, Department of Paediatric Medicine, KK Women's and Children's Hospital, Singapore
| | | | - Despo Ierodiakonou
- Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus
| | - Joan Bartra
- Hospital Clínic de Barcelona, Barcelona, Spain
| | - Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Paul J Turner
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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Nagamine T. Beware of Biphasic Anaphylaxis. J Emerg Med 2021; 61:207-208. [PMID: 34392936 DOI: 10.1016/j.jemermed.2021.02.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/21/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Takahiko Nagamine
- Sunlight Brain Research Center, Hofu, Yamaguchi, Japan; Department of Emergency Medicine, Matsumoto Surgical Hospital, Hofu, Yamaguchi, Japan.
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