Pediatricians manage anaphylaxis poorly regardless of episode severity

Physicians' Approach to Anaphylaxis in Childhood

METHODS

A questionnaire form consisting of a total of 18 questions was prepared. Six questions concerned demographic data; 7 questions inquired about physician's knowledge level about treatment of anaphylaxis. In the last part, 5 different case scenarios were given, and their diagnoses and treatments were asked.

RESULTS

A total of 120 physicians participated in the study. Of the participants, 66.7% were residents. The rate of correct answer about dose of epinephrine was 57.5%. The rates of making correct diagnoses in anaphylaxis case scenarios 1, 2, and 3 were 60%, 73.3%, and 91.7%, respectively, whereas epinephrine administration rates were 54%, 67.5%, and 92.5%, respectively. When the answers of all these questions given by the residents and specialists and among physicians who updated and did not update were compared, there were no statistically significant differences except epinephrine administration rate and its route (P < 0.05).

CONCLUSIONS

The results of the current study suggest that physicians' knowledge levels were inadequate in making the diagnosis of anaphylaxis, and physicians use epinephrine in conditions without hypotension or an undefined possible/known allergen contact. Information about epinephrine administration was partially correct. It is currently considered to be the simplest measure to have a written anaphylaxis action plan including diagnostic criteria for anaphylaxis.

Do Pediatric Emergency Physicians Comply With Guideline Recommendations in Management of Patients With Acute Urticaria?

OBJECTIVES

To determine the level of knowledge and practical preferences of pediatricians regarding acute urticaria (AU) management and to assess the effects of training provided in accordance with the current urticaria guideline recommendations on pediatricians who work in the pediatric emergency department (PED).

METHODS

A theoretical training was provided to pediatricians regarding the diagnosis and treatment of AU in line with current urticaria guideline recommendations. Before the training, pediatricians completed a 10-item questionnaire. This prospective study assesses their treatment approaches in patients admitted to PED because of AU during the 6-month period before and the 1-year period after training.

RESULTS

Four hundred seventeen children in the pretraining and 1085 children in the posttraining periods were treated for AU in PED. Forty-eight pediatricians participated in the training. According to their questionnaire responses, 35% of them used only H1 antihistamine (AH) treatment, 50% used second-generation H1 AH (2nd-GAH) as AHs, 75% preferred the oral route of administration, and 85.4% did not administer systemic corticosteroid (sCS) to all patients. Comparing the practice approaches of the pediatricians in the pretraining and posttraining periods, first-generation H1 antihistamine (1st-GAH) preference rate decreased from 68.4% to 30.3% and the sCS preference rate decreased from 58.5% to 25.7%, while the 2nd-GAH preference rate increased from 31.7% to 69.7% (P < 0.001 for all). No treatments were prescribed for 10.8% of patients before the training and 3% after the training during discharge at home (P < 0.05). Comparing the home treatment choices of the pediatricians in the pretraining and posttraining periods, 1st-GAH preference rate decreased from 11.5% to 5%, while the 2nd-GAH preference rate increased from 78.7% to 91.5% (for both parameters, P < 0.001).

CONCLUSIONS

Practical treatment preferences of pediatricians in the treatment of children with AU differ considerably from both current guideline recommendations and their own theoretical knowledge, and training can enhance pediatricians' compliance with current guideline recommendations.

Physicians' knowledge regarding epinephrine underuse in anaphylaxis

BACKGROUND

Anaphylaxis is a life-threating hypersensitivity reaction. Epinephrine underuse in patients with anaphylaxis could lead to poor outcomes. There is evidence that the epinephrine use in such patients could be as low as 8%.

OBJECTIVE

To assess the percentage of physicians who know that epinephrine is the first-line treatment in anaphylaxis. The secondary objective was to assess knowledge gaps regarding anaphylaxis diagnosis and treatment that could lead to epinephrine underuse.

METHODS

We performed an online survey for physicians in Mexico City, using a 10-item questionnaire assessing anaphylaxis knowledge. We obtained measures of central tendency for statistical analysis, such as frequency, 95% confidence interval, as well as the chi-square test for comparing the groups.

RESULTS

A total of 196 surveys were considered for analysis. Of all the participants, 96.44% were able to correctly diagnose an anaphylaxis case with cutaneous, respiratory, and cardiovascular symptoms. Fifty-two percent correctly diagnosed anaphylaxis without cutaneous symptoms. The 72.4% of the respondents chose epinephrine as the first-line treatment, 42.3% correctly answered that there is no absolute contraindication to giving epinephrine, and 20.9% ignored whether there was any contraindication for its use. Only 38.3% of participants answered that during discharge they would prescribe an autoinjector. Regarding the administration route, 63.4% answered that the first dose of epinephrine is applied intramuscularly and 50% of the participants chose the correct dose of epinephrine. Only 2.6% of the participants answered all 10 questions correctly.

CONCLUSION

There is still some difficulty recognizing anaphylaxis without cutaneous symptoms. Even though two-thirds of physicians identified that epinephrine is the treatment of choice, only 49.5% would have used intramuscular epinephrine as first-line treatment. We found a low percentage of epinephrine ampule prescription and knowledge of the correct dose. These findings can account for epinephrine underuse when dealing with anaphylaxis in the real clinical practice.

Current Situation of Treatment for Anaphylaxis in a Japanese Pediatric Emergency Center

OBJECTIVE

Anaphylaxis is a systemic allergic reaction that sometimes requires prompt treatment with intramuscular adrenaline. The aim of the study was to investigate the current situation regarding anaphylaxis treatment in a representative pediatric primary emergency facility in Japan.

METHODS

We retrospectively examined the medical records dating from April 2011 through March 2014 from Kobe Children's Primary Emergency Medical Center, where general pediatricians work on a part-time basis. Clinical characteristics and current treatments for patients with anaphylaxis who presented to the facility were investigated. Furthermore, we compared the clinical characteristics between anaphylaxis patients given intramuscular adrenaline and those not given it.

RESULTS

During the study period, 217 patients were diagnosed with anaphylaxis. The median Sampson grade at the time of visit was 2, and 90 patients (41%) were grade 4 or higher. No patients received self-intramuscular injected adrenaline before arrival at our emergency medical center because none of the patients had been prescribed it. Further treatment during the visit was provided to 128 patients (59%), with only 17 (8%) receiving intramuscular adrenaline. Patients given intramuscular adrenaline had significantly lower peripheral saturation of oxygen at the visit (P = 0.025) and more frequent transfer to a referral hospital (P < 0.001) than those not given intramuscular adrenaline.

CONCLUSIONS

Education for Japanese pediatric practitioners and patients is warranted, because no patients used self-intramuscular injected adrenaline as a prehospital treatment for anaphylaxis, and only severely affected patients who needed oxygen therapy or hospitalization received intramuscular adrenaline in a pediatric primary emergency setting.

Diagnosis and treatment of anaphylaxis: there is an urgent needs to implement the use of guidelines

Anaphylaxis is a severe, life-threatening generalized or systemic hypersensitivity reaction that requires rapid and adequate care. This study aimed to obtain an integrated view of the level of physicians' knowledge related with treatment of anaphylaxis in studies published within the last 5 years. Sixteen studies were found and four points were identified as of the great interest to the authors: (1) emergency pharmacological treatment, (2) epinephrine auto-injectors prescription, (3) knowledge of the main signs of anaphylaxis, and (4) admission of the patient to verify biphasic reactions. Concern about the use of intramuscular adrenaline as the first choice in relation with anaphylaxis was evident in most studies, rather than its use in the comparison dial, and especially low in a study that included data from Brazil, in which the frequency of its use was 23.8%. An adrenaline autoinjector is highly recommended among specialists for patients at risk of anaphylaxis, however, its use is still infrequent among non-specialists and in countries that this agent is not available. Intervention studies have shown improved medical knowledge of anaphylaxis following disclosure of the information contained in the international guidelines. The analysis of these studies reinforces the need to disseminate international guidelines for diagnosis and treatment of anaphylaxis, as well as providing an adrenaline autoinjector, to improve management and to prevent a fatal outcome.