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Wang W, Zhang Y, Tao L, Jiang TX, Wang N, Zhai WH. Adrenaline intravenous therapy persistence grade I severe allergic reaction: A case report and literature review. Medicine (Baltimore) 2024; 103:e39193. [PMID: 39093789 PMCID: PMC11296400 DOI: 10.1097/md.0000000000039193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/16/2024] [Indexed: 08/04/2024] Open
Abstract
RATIONALE At present, there is still insufficient understanding of the progression from persistent allergic reactions to severe reactions. Adrenaline remains the preferred medication for severe allergic reactions, and intramuscular injection of adrenaline can also be considered for patients with grade I reactions that are difficult to alleviate gastrointestinal symptoms. It is worth further discussing whether it is possible to break the conventional intramuscular injection recommended by the guidelines when the effect of intramuscular injection is not ideal for persistent grade I severe allergic reactions. PATIENT CONCERNS A young male, 20 years of age, was admitted to emergency department because of repeated rash for 3 days and abdominal pain for 6 hours after taking traditional Chinese medicine. After hormone therapy, the rash continued to recur and secondary gastrointestinal symptoms occurred on the 3th day. Adrenaline intramuscular injection was given to temporarily relieve the rash and abdominal pain, but symptoms still persisted. DIAGNOSIS The patient was diagnosed with persistent severe allergic reaction (grade I). INTERVENTIONS Continuous intravenous infusion of low-dose adrenaline under electrocardiographic monitoring, real-time monitoring of heart rate and blood pressure, and routine treatment with methylprednisolone, diphenhydramine, calcium gluconate, and cetirizine. During this period, adrenaline intramuscular injection is temporarily added when abdominal pain symptoms are obvious. The entire treatment process used a total of 6.8 mg of adrenaline. OUTCOMES During the entire period of adrenaline intervention, the patient did not experience any new discomfort, and there were no abnormal fluctuations in heart rate, rhythm, or blood pressure. The symptoms of rash and abdominal pain gradually improved. LESSONS For patients with persistent grade I severe allergic reactions, intravenous administration of low-dose adrenaline under close vital sign monitoring is safe, feasible, and highly effective in preventing biphasic, persistent, or worsening allergic reactions.
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Affiliation(s)
- Wei Wang
- Emergency Department, 305 Hospital of PLA, Beijing, China
| | - Ying Zhang
- Emergency Department, 305 Hospital of PLA, Beijing, China
| | - Li Tao
- Emergency Department, 305 Hospital of PLA, Beijing, China
| | - Tong-Xue Jiang
- Outpatient Department, 305 Hospital of PLA, Beijing, China
| | - Ning Wang
- Emergency Department, 305 Hospital of PLA, Beijing, China
| | - Wen-Hui Zhai
- Emergency Department, 305 Hospital of PLA, Beijing, China
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Delli Colli L, Al Ali A, Gabrielli S, Delli Colli M, Mule P, Lawson B, Clarke AE, Morris J, Gravel J, Lim R, Chan ES, Goldman RD, O'Keefe A, Gerdts J, Chu DK, Upton J, Hochstadter E, Bretholz A, McCusker C, Zhang X, Benor S, Simons E, Abrams EM, Protudjer JLP, Ben-Shoshan M. Managing anaphylaxis: Epinephrine, antihistamines, and corticosteroids: More than 10 years of Cross-Canada Anaphylaxis REgistry data. Ann Allergy Asthma Immunol 2023; 131:752-758.e1. [PMID: 37689113 DOI: 10.1016/j.anai.2023.08.606] [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] [Received: 03/09/2023] [Revised: 08/04/2023] [Accepted: 08/22/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Epinephrine is the first-line treatment for anaphylaxis but is often replaced with antihistamines or corticosteroids. Delayed epinephrine administration is a risk factor for fatal anaphylaxis. Convincing data on the role of antihistamines and corticosteroids in anaphylaxis management are sparse. OBJECTIVE To establish the impact of prehospital treatment with epinephrine, antihistamines, and/or corticosteroids on anaphylaxis management. METHODS Patients presenting with anaphylaxis were recruited prospectively and retrospectively in 10 Canadian and 1 Israeli emergency departments (EDs) between April 2011 and August 2022, as part of the Cross-Canada Anaphylaxis REgistry. Data on anaphylaxis cases were collected using a standardized form. Primary outcomes were uncontrolled reactions (>2 doses of epinephrine in ED), no prehospital epinephrine use, use of intravenous fluids in ED, and hospital admission. Multivariate regression was used to identify factors associated with primary outcomes. RESULTS Among 5364 reactions recorded, median age was 8.8 years (IQR, 3.78-16.9); 54.9% of the patients were males, and 52.5% had a known food allergy. In the prehospital setting, 37.9% received epinephrine; 44.3% received antihistamines, and 3.15% received corticosteroids. Uncontrolled reactions happened in 250 reactions. Patients treated with prehospital epinephrine were less likely to have uncontrolled reactions (adjusted odds ratio [aOR], 0.955 [95% CI, 0.943-0.967]), receive intravenous fluids in ED (aOR, 0.976 [95% CI, 0.959-0.992]), and to be admitted after the reaction (aOR, 0.964 [95% CI, 0.949-0.980]). Patients treated with prehospital antihistamines were less likely to have uncontrolled reactions (aOR, 0.978 [95% CI, 0.967-0.989]) and to be admitted after the reaction (aOR, 0.963 [95% CI, 0.949-0.977]). Patients who received prehospital corticosteroids were more likely to require intravenous fluids in ED (aOR, 1.059 [95% CI, 1.013-1.107]) and be admitted (aOR, 1.232 [95% CI, 1.181-1.286]). CONCLUSION Our findings in this predominantly pediatric population support the early use of epinephrine and suggest a beneficial effect of antihistamines. Corticosteroid use in anaphylaxis should be revisited.
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Affiliation(s)
- Luca Delli Colli
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada.
| | - Adnan Al Ali
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sofianne Gabrielli
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marina Delli Colli
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Pasquale Mule
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Benjamin Lawson
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ann E Clarke
- Division of Rheumatology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Judy Morris
- Department of Emergency Medicine, Sacré-Coeur Hospital, Montreal, Quebec, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Université de Montréal, Quebec, Canada
| | - Rod Lim
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital at London Health Science Centre, London, Ontario, Canada
| | - Edmond S Chan
- Division of Allergy and Immunology, Department of Pediatrics, BC Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ran D Goldman
- Division of Clinical Pharmacology and Emergency Medicine, Department of Pediatrics, BC Children's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew O'Keefe
- Faculty of Medicine, Department of Pediatrics, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Jennifer Gerdts
- Executive Director, Food Allergy Canada, Toronto, Ontario, Canada
| | - Derek K Chu
- Division of Clinical Immunology & Allergy, Department of Medicine, and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Julia Upton
- Division of Immunology and Allergy, Department of Pediatrics, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Elana Hochstadter
- Department of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Adam Bretholz
- Department of Pediatric Emergency Medicine, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Christine McCusker
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Xun Zhang
- Center for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada
| | - Shira Benor
- Allergy and Clinical Immunology Unit, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Elinor Simons
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, University of Manitoba, and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer L P Protudjer
- Department of Pediatrics and Child Health, University of Manitoba and Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; George and Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Moshe Ben-Shoshan
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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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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