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Pouessel G, Dribin TE, Tacquard C, Tanno LK, Cardona V, Worm M, Deschildre A, Muraro A, Garvey LH, Turner PJ. Management of Refractory Anaphylaxis: An Overview of Current Guidelines. Clin Exp Allergy 2024; 54:470-488. [PMID: 38866583 DOI: 10.1111/cea.14514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 06/14/2024]
Abstract
In this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second-line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta-blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor-acetyl hydrolase or hereditary alpha-tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis.
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Affiliation(s)
- Guillaume Pouessel
- Department of Paediatrics, Children's Hospital, Roubaix, France
- Paediatric Pulmonology and Allergy Department, Jeanne de Flandre Hospital, CHU Lille, Lille, France
- Univ Lille, ULR 2694: METRICS, Lille, France
| | - Timothy E Dribin
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Charles Tacquard
- Department of Anaesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Luciana Kase Tanno
- University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, University of Montpellier - INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Victoria Cardona
- Department of Allergy, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Berlin, Germany
| | - Antoine Deschildre
- Paediatric Pulmonology and Allergy Department, Jeanne de Flandre Hospital, CHU Lille, Lille, France
| | - Antonella Muraro
- Food Allergy Referral Centres, Padua University Hospital, Padua, Italy
| | - Lene H Garvey
- Department of Dermatology and Allergy, Danish Anaesthesia Allergy Centre, Allergy Clinic, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, UK
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Pouessel G, Tacquard C, Tanno LK, Mertes PM, Lezmi G. Anaphylaxis mortality in the perioperative setting: Epidemiology, elicitors, risk factors and knowledge gaps. Clin Exp Allergy 2024; 54:11-20. [PMID: 38168878 DOI: 10.1111/cea.14434] [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: 07/03/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
Perioperative anaphylaxis (PA) is a severe condition that can be fatal, but data on PA mortality are scarce. The aim of this article is to review the epidemiology, elicitors and risk factors for PA mortality and identify knowledge gaps and areas for improvement regarding the management of severe PA. PA affects about 100 cases per million procedures. Mortality is rare, estimated at 3 to 5 cases per million procedures, but the PA mortality rate is higher than for other anaphylaxis aetiologies, at 1.4% to 4.8%. However, the data are incomplete. Published data mention neuromuscular blocking agents and antibiotics, mainly penicillin and cefazolin, as the main causes of fatal PA. Reported risk factors for fatal PA vary in different countries. Most frequently occurring comorbidities are obesity, male gender, cardiovascular diseases and ongoing treatment with beta-blockers. However, there are no clues about how these factors interact and the impact of individual risk factors. The pathophysiology of fatal PA is still not completely known. Genetic factors such as deficiency in PAF-acetyl hydrolase and hereditary alpha-tryptasemia, have been reported as modulators of severe anaphylaxis and possible targets for specific treatments. Our review underlines unmet needs in the field of fatal PA. Although we confirmed the need for timely administration of an adequate dose of adrenaline and the proper infusion of fluids, there is no evidence-based data on the proper dose of intravenous titrated adrenaline and which clinical manifestations would flag the need for fluid therapy. There are no large clinical studies supporting the administration of alternative vasopressors, such as glucagon and methylene blue. Further research on pathophysiological mechanisms of PA and its severity may address these issues and help clinicians to define new therapeutic approaches.
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Affiliation(s)
- Guillaume Pouessel
- Department of Pediatrics, Children's Hospital, CH Roubaix, Roubaix, France
- Pediatric Pulmonology and Allergy Department, Pôle enfant, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
- ULR 2694: METRICS, Univ Lille, Lille, France
| | - Charles Tacquard
- Department of Anaesthesia and Intensive Care, Strasbourg University Hospital, Strasbourg, France
| | - Luciana Kase Tanno
- Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier - INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Paul Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Guillaume Lezmi
- Paediatric Pneumology and Allergology Unit, Children's Hospital Necker, Paris, France
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Yang BC. Biologics to treat anaphylaxis. Curr Opin Allergy Clin Immunol 2023; 23:370-375. [PMID: 37527059 DOI: 10.1097/aci.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW The purpose of this literature review was to review the latest use of biologics in the management of anaphylaxis. The methodology was to highlight both the nonbiologic management of anaphylaxis and the biologic management and how they can be used in conjunction with each other. RECENT FINDINGS As the phenotypes and endotypes of anaphylaxis are better portrayed, it furthers our understanding of the mechanisms of anaphylaxis. New applications of existing biologics to the prevention of anaphylaxis are described. SUMMARY Anaphylaxis is a potentially life-threatening acute hypersensitivity reaction affecting up to 16.8% of the U.S. population. Acute management entails swift identification, removal of the causative agent, and the prevention of cardiovascular collapse, firstly with epinephrine. Adjunctive treatments such as antihistamines work to prevent anaphylaxis from recurring. Biologic management of anaphylaxis involves the use of large-molecule drugs such as monoclonal antibodies. Omalizumab, an IgG1 monoclonal antibody targeting unbound IgE, is the most prevalent and widely studied biologic in the prevention of anaphylaxis. Other monoclonal antibodies in development or approved for other indications, such as ligelizumab, quilizumab, MEDI4212, and dupilumab, may also have potential for preventing anaphylaxis through various mechanisms.
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Arasi S, Nurmatov U, Dunn-Galvin A, Roberts G, Turner PJ, Shinder SB, Gupta R, Eigenmann P, Nowak-Wegrzyn A, Ansotegui IJ, Rivas MF, Petrou S, Tanno LK, Vazquez-Ortiz M, Vickery B, Wong G, Alvaro-Lozano M, Asaria M, Begin P, Bozzola M, Boyle R, Brough H, Cardona V, Chinthrajah RS, Cianferoni A, Deschildre A, Fleischer D, Gazzani F, Gerdts J, Giannetti M, Greenhawt M, Guzmán MA, Hossny E, Kauppi P, Jones C, Lucidi F, Monge Ortega OP, Munblit D, Muraro A, Pajno G, Podestà M, Rodriguez del Rio P, Said M, Santos A, Shaker M, Szajewska H, Venter C, Warren C, Winders T, Ebisawa M, Fiocchi A. WAO consensus on DEfinition of Food Allergy SEverity (DEFASE). World Allergy Organ J 2023; 16:100753. [PMID: 36910595 PMCID: PMC9996094 DOI: 10.1016/j.waojou.2023.100753] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/20/2023] [Accepted: 02/03/2023] [Indexed: 03/06/2023] Open
Abstract
Background While several scoring systems for the severity of anaphylactic reactions have been developed, there is a lack of consensus on definition and categorisation of severity of food allergy disease as a whole. Aim To develop an international consensus on the severity of food allergy (DEfinition of Food Allergy Severity, DEFASE) scoring system, to be used globally. Methods Phase 1 We conducted a mixed-method systematic review (SR) of 11 databases for published and unpublished literature on severity of food allergy management and set up a panel of international experts. Phase 2 Based on our findings in Phase 1, we drafted statements for a two-round modified electronic Delphi (e-Delphi) survey. A purposefully selected multidisciplinary international expert panel on food allergy (n = 60) was identified and sent a structured questionnaire, including a set of statements on different domains of food allergy severity related to symptoms, health-related quality of life, and economic impact. Participants were asked to score their agreement on each statement on a 5-point Likert scale ranging from "strongly agree" to "strongly disagree". Median scores and percentage agreements were calculated. Consensus was defined a priori as being achieved if 70% or more of panel members rated a statement as "strongly agree" to "agree" after the second round. Based on feedback, 2 additional online voting rounds were conducted. Results We received responses from 92% of Delphi panel members in round 1 and 85% in round 2. Consensus was achieved on the overall score and in all of the 5 specific key domains as essential components of the DEFASE score. Conclusions The DEFASE score is the first comprehensive grading of food allergy severity that considers not only the severity of a single reaction, but the whole disease spectrum. An international consensus has been achieved regarding a scoring system for food allergy disease. It offers an evaluation grid, which may help to rate the severity of food allergy. Phase 3 will involve validating the scoring system in research settings, and implementing it in clinical practice.
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Affiliation(s)
- Stefania Arasi
- Allergy Diseases Research Area, Pediatric Allergology Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Ulugbek Nurmatov
- Division of Population Medicine, School of Medicine, Cardiff University, Wales, UK
| | - Audrey Dunn-Galvin
- Applied Psychology and Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Graham Roberts
- Faculty of Medicine, University of Southampton, Southampton, UK
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul J. Turner
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Sayantani B. Shinder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Stanford University, Stanford, CA, USA
| | - Ruchi Gupta
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Philippe Eigenmann
- Department of Pediatrics, Gynecology and Obstetrics, University Hospital of Geneva, Geneva, Switzerland
| | - Anna Nowak-Wegrzyn
- Allergy and Immunology, Department of Pediatrics, New York University School of Medicine, Langone Health, New York, NY, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
| | - Montserrat Fernandez Rivas
- Allergy Department, Hospital Clinico San Carlos, Instituto de Investigacion Sanitaria San Carlos (IdISSC), Universidad Complutense, Madrid, Spain
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford
- Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
- Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England, UK
| | - Luciana K. Tanno
- Division of Allergy, Department of Pulmonology, University Hospital of Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UA-11, INSERM University of Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Brian Vickery
- Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Gary Wong
- Department of Paediatrics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - Montserrat Alvaro-Lozano
- Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Deu, Barcelona, Spain
- Institut de Recerca Sant Joan de Deu, Barcelona, Spain
- Universitat de Barcelona, Spain
| | - Miqdad Asaria
- Department of Health Policy, London School of Economics and Political Science, UK
| | - Philippe Begin
- Allergy, immunology and Rheumatology Division, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
- Allergy and Clinical immunology Division, Department of Medicine, Centre Hospitalier de l’Université de Montréal, QC, Canada
| | - Martin Bozzola
- Hospital Britanico de Buenos Aires Buenos Aires, Argentina
| | - Robert Boyle
- National Heart and Lung Institute, Imperial College London, UK
| | - Helen Brough
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital, London, UK
- Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Victoria Cardona
- Allergy Section, Department of Internal Medicine, Hospital Vall D’Hebron, Barcelona, Spain
- ARADyAL Research Network, Spain
| | | | - Antonella Cianferoni
- The Children's Hospital of Philadelphia, The University of Pennsylvania, Philadelphia, PA, United States
| | - Antoine Deschildre
- CHU Lille, Univ Lille, Pediatric Allergy and Pulmonology Unit, Hôpital Jeanne de Flandre, 59000 Lille, France
- Section of Pediatric Allergy & Immunology, Children's Hospital Colorado, USA
| | | | - Flavio Gazzani
- Departement of Economics and Law, University of Rome La Sapienza, Italy
| | - Jennifer Gerdts
- Executive Director, Food Allergy Canada, Toronto, Ontario, Canada
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Elham Hossny
- Pediatric Allergy, Immunology and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Paula Kauppi
- University of Helsinki and Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Carla Jones
- Chief Executive of Patient Organisation, Allergy UK, London, UK
| | - Francesco Lucidi
- Allergology Unit of the San Juan de Dios Hospital, San José, Costa Rica
| | | | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
- Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - Antonella Muraro
- Food Allergy Centre Department of Woman and Child Health Padua University Hospital, Padua Italy
| | - Giovanni Pajno
- Pediatric Unit- Policlinico Hospital, University of Messina, Messina, Italy
| | | | | | - Maria Said
- CEO Allergy & Anaphylaxis Australia, Sydney, Australia
| | - Alexandra Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Marcus Shaker
- Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
- Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
- Dartmouth Geisel School of Medicine and Dartmouth-Hitchcock Medical Center, Lebanon
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Carina Venter
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cristopher Warren
- Center for Food Allergy and Asthma Research, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, USA
| | - Tonya Winders
- Allergy & Asthma Network (AAN), President and CEO, Allergy and Asthma Network, Vienna, VA, USA
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara Japan
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Yıldız E, Arslan Ş, Çölkesen F, Evcen R, Sadi Aykan F, Kılınç M. Anaphylaxis in older adult patients: a 10-year retrospective experience. World Allergy Organ J 2022; 15:100665. [PMID: 35891674 PMCID: PMC9293944 DOI: 10.1016/j.waojou.2022.100665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/25/2022] Open
Abstract
Background Despite the worldwide increase in life expectancy and the elderly population, very little is known about the characteristics of anaphylaxis in older adults. Methods A retrospective scan was made of the files of patients who presented at the Allergy Unit of our clinic between October 2011 and October 2021. The study included 971 patients aged ≥18 years who met the criteria for diagnosis of anaphylaxis. The patients were separated into 2 groups of adults (18–64 years) and older adults (≥65 years). Results The adult group included 887 (91.3%) patients and the older adult group, 84 (8.7%) patients. Comorbid diseases were seen more frequently in the older adults than in the adult group (p < 0.001). Drugs were seen to be the most common trigger of anaphylaxis in both groups, and this was more common in the older adult group (p = 0.039). Food was a more common trigger of anaphylaxis in the adult group than in the older adult group (p = 0.017). In both groups, the skin was the organ most affected, and was less affected in the older adults than in the adults (p = 0.020). Cardiovascular symptoms were seen significantly more and respiratory symptoms significantly less in the older adult group (p < 0.001, p = 0.002, respectively). Admission to the hospital and the intensive care unit was more frequent in the older adult group and rates of adrenalin administration were higher compared to the adult group (p < 0.001 for all). Conclusion Anaphylaxis in the older adults is generally caused by drugs. Older adults were found to have more cardiovascular symptoms and more frequent adrenalin injections, hospitalizations and intensive care unit admissions.
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Affiliation(s)
- Eray Yıldız
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Şevket Arslan
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Fatih Çölkesen
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Recep Evcen
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Filiz Sadi Aykan
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Mehmet Kılınç
- Division of Clinical Immunology and Allergy, Department of Internal Medicine, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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Li X, Ma Q, Yin J, Zheng Y, Chen R, Chen Y, Li T, Wang Y, Yang K, Zhang H, Tang Y, Chen Y, Dong H, Gu Q, Guo D, Hu X, Xie L, Li B, Li Y, Lin T, Liu F, Liu Z, Lyu L, Mei Q, Shao J, Xin H, Yang F, Yang H, Yang W, Yao X, Yu C, Zhan S, Zhang G, Wang M, Zhu Z, Zhou B, Gu J, Xian M, Lyu Y, Li Z, Zheng H, Cui C, Deng S, Huang C, Li L, Liu P, Men P, Shao C, Wang S, Ma X, Wang Q, Zhai S. A Clinical Practice Guideline for the Emergency Management of Anaphylaxis (2020). Front Pharmacol 2022; 13:845689. [PMID: 35418863 PMCID: PMC8996305 DOI: 10.3389/fphar.2022.845689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background: For anaphylaxis, a life-threatening allergic reaction, the incidence rate was presented to have increased from the beginning of the 21st century. Underdiagnosis and undertreatment of anaphylaxis are public health concerns. Objective: This guideline aimed to provide high-quality and evidence-based recommendations for the emergency management of anaphylaxis. Method: The panel of health professionals from fifteen medical areas selected twenty-five clinical questions and formulated the recommendations with the supervision of four methodologists. We collected evidence by conducting systematic literature retrieval and using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: This guideline made twenty-five recommendations that covered the diagnosis, preparation, emergency treatment, and post-emergency management of anaphylaxis. We recommended the use of a set of adapted diagnostic criteria from the American National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network (NIAID/FAAN), and developed a severity grading system that classified anaphylaxis into four grades. We recommended epinephrine as the first-line treatment, with specific doses and routes of administration for different severity of anaphylaxis or different conditions. Proper dosage is critical in the administration of epinephrine, and the monitor is important in the IV administration. Though there was only very low or low-quality evidence supported the use of glucocorticoids and H1 antagonists, we still weakly recommended them as second-line medications. We could not make a well-directed recommendation regarding premedication for preventing anaphylaxis since it is difficult to weigh the concerns and potential effects. Conclusion: For the emergency management of anaphylaxis we conclude that: • NIAID/FAAN diagnostic criteria and the four-tier grading system should be used for the diagnosis • Prompt and proper administration of epinephrine is critical.
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Affiliation(s)
- Xiaotong Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,School of Pharmaceutical Science, Peking University, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Qingbian Ma
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Jia Yin
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ya'an Zheng
- Emergency Department, Peking University Third Hospital, Beijing, China
| | - Rongchang Chen
- State Key Laboratory for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuguo Chen
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Institute of Emergency and Critical Care Medicine of Shandong University, Ji'nan, China
| | - Tianzuo Li
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Yuqin Wang
- Pharmacy Department, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hongjun Zhang
- Departments of Nursing, Peking University Third Hospital, Beijing, China
| | - Yida Tang
- Department of Internal Medicine, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Qinglong Gu
- Department of Otolaryngology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Daihong Guo
- Pharmacy Department, Chinese PL A General Hospital, Beijing, China
| | - Xuehui Hu
- Department of Nursing, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Lixin Xie
- Department of Pulmonary and Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Baohua Li
- Departments of Nursing, Peking University Third Hospital, Beijing, China
| | - Yuzhen Li
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Tongyu Lin
- State Key Laboratory of Oncology in South China, Department of Medical Oncology, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Fang Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lanting Lyu
- School of Public Administration and Policy, Renmin University of China, Beijing, China.,Health Technology Assessment and Health Policy Research Group at Renmin University of China, Beijing, China
| | - Quanxi Mei
- Department of Pharmacy, Shenzhen Bao'an Pure Chinese Medicine Treatment Hospital, Shenzhen, China
| | - Jie Shao
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Huawen Xin
- Department of Clinical Pharmacology, General Hospital of Central Theater Command of PLA, Wuhan, China
| | - Fan Yang
- Institute of Antibiotics, Huashan Hospital Fudan University, Shanghai, China
| | - Hui Yang
- Departments of Nursing, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Wanhua Yang
- Department of Pharmacy, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xu Yao
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China
| | - Chunshui Yu
- Department of Radiology and Tianjin Key Laboratory of Functional Imaging, Tianjin Medical University General Hospital, Tianjin, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Guoqiang Zhang
- Department of Emergency, China-Japan Friendship Hospital, Beijing, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital Fudan University, Shanghai, China
| | - Zhu Zhu
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Baoguo Zhou
- Department of General Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jianqing Gu
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mo Xian
- State Key Laboratory for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuan Lyu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Institute of Emergency and Critical Care Medicine of Shandong University, Ji'nan, China
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Hangci Zheng
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,School of Pharmaceutical Science, Peking University, Beijing, China
| | - Chang Cui
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,School of Pharmaceutical Science, Peking University, Beijing, China
| | - Shuhua Deng
- Departments of Nursing, Peking University Third Hospital, Beijing, China
| | - Chao Huang
- National Center for Medical Service Administration, National Health Commission of the People's Republic of China, Beijing, China
| | - Lisha Li
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pengfei Liu
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Peng Men
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,School of Pharmaceutical Science, Peking University, Beijing, China
| | - Chunli Shao
- Department of Internal Medicine, Coronary Heart Disease Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sai Wang
- Pharmacy Department, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Xiang Ma
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Physiology, Oklahoma University Health Science Center, Oklahoma City, OK, United States
| | - Qiang Wang
- National Center for Medical Service Administration, National Health Commission of the People's Republic of China, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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7
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Gouel-Cheron A, Neukirch C, Kantor E, Malinovsky JM, Tacquard C, Montravers P, Mertes PM, Longrois D. Clinical reasoning in anaphylactic shock: addressing the challenges faced by anaesthesiologists in real time: A clinical review and management algorithms. Eur J Anaesthesiol 2021; 38:1158-1167. [PMID: 33973926 DOI: 10.1097/eja.0000000000001536] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute hypersensitivity reactions to drugs occur infrequently during anaesthesia and the peri-operative period. When clinical presentation includes the classical triad, erythema, cardiovascular abnormalities and increased airway pressure, the diagnosis is evident and the challenge is to prescribe a therapeutic regimen according to guidelines and to manage refractory signs in a timely manner. In many situations, however, the initial clinical signs are isolated, such as increased airway pressure or arterial hypotension. Rendering a differential diagnosis with causes and mechanisms other than acute hypersensitivity reactions (AHRs) is difficult, delaying treatment with possible worsening of the clinical signs, and even death, in previously healthy individuals. In these difficult diagnostic situations, clinical reasoning is mandatory, and guidelines do not explicitly explain the elements on which clinical reasoning can be built. In this article, based on clinical evidence whenever available, experimental data and pathophysiology, we propose algorithms that have been evaluated by experts. The goal of these algorithms is to provide explicit elements on which the differential diagnosis of AHRs can be made, accelerating the implementation of adequate therapy.
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Affiliation(s)
- Aurelie Gouel-Cheron
- From the Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP (AGC, EK, PM, DL), Antibody in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM, Paris, France (AGC), Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA (AGC), Pulmonology Department, Bichat Hospital, AP-HP, Paris University (CN), INSERM UMR 1152, Paris University, DHU FIRE, Paris (CN, PM), Anaesthesiology and Critical Care Medicine Department, Maison Blanche Hospital, Centre Hospitalier Universitaire de Reims, Reims (JM-M), Anaesthesiology and Critical Care Medicine Department, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (CT, PM-M), Paris University (PM, DL), EA 3072, Institut de Physiologie, FMTS, Faculté de Médecine de Strasbourg, Université de Strasbourg, Strasbourg (PM-M) and INSERM1148, Paris, France (DL)
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8
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Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review. Crit Care Med 2021; 49:838-857. [PMID: 33653974 DOI: 10.1097/ccm.0000000000004893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications. DATA SOURCES A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane). STUDY SELECTION Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications. DATA EXTRACTION Data from the relevant publications were reviewed, summarized and the information synthesized. DATA SYNTHESIS This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions. CONCLUSION Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.
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9
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Long CS, Miller MR, McMullin GM, Tivey SL. Transesophageal Echocardiography-Guided Cardiopulmonary Resuscitation After Rocuronium Anaphylaxis. A A Pract 2020; 14:e01175. [DOI: 10.1213/xaa.0000000000001175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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10
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Medikamenteninduzierte Anaphylaxie: Auslöser, Mechanismen und Diagnose. ALLERGO JOURNAL 2019. [DOI: 10.1007/s15007-019-1984-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Francuzik W, Dölle-Bierke S, Knop M, Scherer Hofmeier K, Cichocka-Jarosz E, García BE, Lang R, Maris I, Renaudin JM, Worm M. Refractory Anaphylaxis: Data From the European Anaphylaxis Registry. Front Immunol 2019; 10:2482. [PMID: 31749797 PMCID: PMC6842952 DOI: 10.3389/fimmu.2019.02482] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 10/04/2019] [Indexed: 12/12/2022] Open
Abstract
Refractory anaphylaxis (unresponsive to treatment with at least two doses of minimum 300 μg adrenaline) is a rare and often fatal hypersensitivity reaction. Comprehensive data on its definition, prevalence, and risk factors are missing. Using the data from the European Anaphylaxis Registry (11,596 cases in total) we identified refractory anaphylaxis cases (n = 42) and analyzed these in comparison to a control group of severe anaphylaxis cases (n = 4,820). The data show that drugs more frequently elicited refractory anaphylaxis (50% of cases, p < 0.0001) compared to other severe anaphylaxis cases (19.7%). Cases elicited by insects (n = 8) were more often due to bees than wasps in refractory cases (62.5 vs. 19.4%, p = 0.009). The refractory cases occurred mostly in a perioperative setting (45.2 vs. 9.05, p < 0.0001). Intramuscular adrenaline (as a first line therapy) was administered in 16.7% of refractory cases, whereas in 83.3% of cases it was applied intravenously (significantly more often than in severe anaphylaxis cases: 12.3%, p < 0.0001). Second line treatment options (e.g., vasopression with dopamine, methylene blue, glucagon) were not used at all for the treatment of refractory cases. The mortality rate in refractory anaphylaxis was significantly higher (26.2%) than in severe cases (0.353%, p < 0.0001). Refractory anaphylaxis is associated with drug-induced anaphylaxis in particular if allergens are given intravenously. Although physicians frequently use adrenaline in cases of perioperative anaphylaxis, not all patients are responding to treatment. Whether a delay in recognition of anaphylaxis is responsible for the refractory case or whether these cases are due to an overflow with mast cell activating substances—requires further studies. Reasons for the low use of second-line medication (i.e., methylene blue or dopamine) in refractory cases are unknown, but their use might improve the outcome of severe refractory anaphylaxis cases.
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Affiliation(s)
- Wojciech Francuzik
- Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sabine Dölle-Bierke
- Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Macarena Knop
- Department of Dermatology and Allergology, Klinikum der Universität München, Munich, Germany
| | | | - Ewa Cichocka-Jarosz
- Department of Pediatrics, Jagiellonian University Medical College, Kraków, Poland
| | - Blanca E García
- Service of Allergology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Roland Lang
- Department of Dermatology, Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - Ioana Maris
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jean-Marie Renaudin
- Réseau d'Allergo-Vigilance (Allergy Vigilance Network), Vandoeuvre les Nancy, France
| | - Margitta Worm
- Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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12
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Worm M, Hanschmann-Mohn T, Scherer Hofmeier K, Cardona V, Turner P, Dölle-Bierke S. Drug-induced anaphylaxis—elicitors, mechanisms and diagnosis. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s40629-019-00109-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Abstract
Drugs are one of the major causes of anaphylaxis. For example 2346 cases of drug-induced anaphylaxis were reported to the anaphylaxis register as of March 2019. The most common triggers of drug-induced anaphylaxis were nonsteroidal anti-inflammatory drugs (NSAIDs; n = 902) and antibiotics (n = 721). Drug-induced anaphylaxis can be caused by IgE-dependent (e.g., penicillins) and IgE-independent mechanisms. Recently MRG-PX2 has been identified as a receptor for non-IgE-dependent mechanisms. Drug-induced anaphylaxis results more frequently in lethal reactions and is more commonly associated with cardiovascular symptoms. Also therapy refractory anaphylaxis is more frequently triggered by drugs. For the diagnosis of drug-induced anaphylaxis current national and international guidelines should be followed including provocation tests to avoid future reactions.
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14
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Aurich S, Dölle-Bierke S, Francuzik W, Bilo MB, Christoff G, Fernandez-Rivas M, Hawranek T, Pföhler C, Poziomkowska-Gȩsicka I, Renaudin JM, Oppel E, Scherer K, Treudler R, Worm M. Anaphylaxis in Elderly Patients-Data From the European Anaphylaxis Registry. Front Immunol 2019; 10:750. [PMID: 31068925 PMCID: PMC6491699 DOI: 10.3389/fimmu.2019.00750] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/20/2019] [Indexed: 01/20/2023] Open
Abstract
Background: Elicitors and symptoms of anaphylaxis are age dependent. However, little is known about typical features of anaphylaxis in patients aged 65 years or more. Methods: The data from the Network for Online Registration of Anaphylaxis (NORA) considering patients aged ≥65 (elderly) in comparison to data from adults (18–64 years) regarding elicitors, symptoms, comorbidities, and treatment measures were analyzed. Results: We identified 1,123 elderly anaphylactic patients. Insect venoms were the most frequent elicitor in this group (p < 0.001), followed by drugs like analgesics and antibiotics. Food allergens elicited less frequently anaphylaxis (p < 0.001). Skin symptoms occurred less frequently in elderly patients (77%, p < 0.001). The clinical symptoms were more severe in the elderly (51% experiencing grade III/IV reactions), in particular when skin symptoms (p < 0.001) were absent. Most strikingly, a loss of consciousness (33%, p < 0.001) and preexisting cardiovascular comorbidity (59%, p < 0.001) were more prevalent in the elderly. Finally, adrenaline was used in 30% of the elderly (vs. 26% in the comparator group, p < 0.001) and hospitalization was more often required (60 vs. 50%, p < 0.001). Discussion and Conclusion: Anaphylaxis in the elderly is often caused by insect venoms and drugs. These patients suffer more often from cardiovascular symptoms, receive more frequently adrenaline and require more often hospitalization. The data indicate that anaphylaxis in the elderly tends to be more frequently life threatening and patients require intensified medical intervention. The data support the need to recognize anaphylaxis in this patient group, which is prone to be at a higher risk for a fatal outcome.
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Affiliation(s)
- Stefanie Aurich
- Department of Dermatology, Venereology and Allergology, LICA-Comprehensive Allergy Center, University Hospital, Leipzig, Germany
| | - Sabine Dölle-Bierke
- Division of Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Wojciech Francuzik
- Division of Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maria Beatrice Bilo
- Allergy Unit, Department of Internal Medicine, University Hospital Ospedali Riuniti, Ancona, Italy
| | - George Christoff
- Faculty of Public Health, Medical University-Sofia, Sofia, Bulgaria.,Allergy Outpatient Unit, Acibadem CityClinic, Medical Centre Tokuda, Sofia, Bulgaria
| | | | - Thomas Hawranek
- Department of Dermatology, University Hospital of the Paracelsus Private Medical University, Salzburg, Austria
| | - Claudia Pföhler
- Department of Dermatology, Venereology and Allergology, Saarland University Medical Center, Homburg, Germany
| | | | | | - Eva Oppel
- Department of Dermatology and Allergy, University Hospital (LMU), Munich, Germany
| | - Kathrin Scherer
- Division of Allergy, Department of Dermatology, University of Basel, Basel, Switzerland
| | - Regina Treudler
- Department of Dermatology, Venereology and Allergology, LICA-Comprehensive Allergy Center, University Hospital, Leipzig, Germany
| | - Margitta Worm
- Division of Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
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