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Lloyd M, Loke P, Mack DP, Sicherer SH, Perkin MR, Boyle R, Yin Leung AS, Lee BW, Levin M, Blumchen K, Fiocchi A, Ebisawa M, Oliveira LCLD, Tang MLK. Varying Approaches to Management of IgE-Mediated Food Allergy in Children Around the World. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1010-1027.e6. [PMID: 36805346 DOI: 10.1016/j.jaip.2023.01.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/17/2023]
Abstract
Food allergy is a chronic disease that affects individuals of all ages and is a significant public health problem globally. This narrative overview examines clinical management strategies for IgE-mediated food allergy in children around the world to understand variations in practice. Information was drawn from clinical practice guidelines, recent research, the websites of professional and governmental bodies with expertise in food allergy, and clinical experts from a broad cross-section of geographical regions. The structure and delivery of clinical services, allergen avoidance and food labeling, and resources to support the management of allergic reactions in the community are discussed in detail. The adoption of emerging food immunotherapies is also explored. Wide variations in clinical management of food allergy were apparent across the different countries. Common themes were continuing issues with access to specialist care and recognition of the need to balance risk reduction with dietary and social restrictions to avoid unnecessary detrimental impacts on the quality of life of food allergy sufferers. Findings highlight the need for standardized presentation of practice and priorities, and may assist clinicians and researchers when engaging with government and funding agencies to address gaps.
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Affiliation(s)
- Melanie Lloyd
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia
| | - Paxton Loke
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Douglas P Mack
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Scott H Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael R Perkin
- Population Health Research Institute, St. George's, University of London, London, United Kingdom
| | - Robert Boyle
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Agnes Sze Yin Leung
- Department of Paediatrics, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin, Hong Kong; Hong Kong Hub of Paediatric Excellence, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bee Wah Lee
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Michael Levin
- Division of Paediatric Allergology, University of Cape Town, Cape Town, South Africa
| | - Katharina Blumchen
- Department of Children and Adolescent Medicine, Division of Pneumology, Allergology and Cystic Fibrosis, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Alessandro Fiocchi
- Translational Research in Paediatric Specialities Area, Allergy Division, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Sagamihara, Japan
| | - Lucila Camargo Lopes de Oliveira
- Department of Paediatrics, Division of Allergy, Clinical Immunology and Rheumatology, Federal University of São Paulo, São Paulo, Brazil
| | - Mimi L K Tang
- Allergy Immunology, Murdoch Children's Research Institute, Parkville, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Department of Allergy and Immunology, Royal Children's Hospital, Parkville, VIC, Australia.
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Kim H, Alizadehfar R, Alqurashi W, Ellis AK, Fischer DA, Roberts H, Torabi B, Waserman S. Epinephrine autoinjectors: individualizing device and dosage to optimize anaphylaxis management in the community setting. Allergy Asthma Proc 2023; 44:45-50. [PMID: 36719691 DOI: 10.2500/aap.2023.44.220073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Anaphylaxis is the most severe manifestation of a systemic allergic reaction, and, in the community setting, the immediate administration of an epinephrine autoinjector (EAI) can be life-saving. Physicians are tasked with selecting the most appropriate EAI for each individual and counseling patients and/or their caregivers to maximize the likelihood of successful deployment of the EAI. Objective: To offer an evidence-based expert clinical perspective on how physicians might best tailor EAI selection to their patients with anaphylaxis. Methods: A group of eight adult and pediatric allergists with expertise in anaphylaxis management reviewed and assessed the published data and guidelines on anaphylaxis management and EAI device selection. Results: Personalized EAI selection is influenced by intrinsic individual factors, extrinsic factors such as the properties of the individual EAI (e.g., dose, needle length, overall design) as well as cost and coverage. The number and the variety of EAIs available have expanded in most jurisdictions in recent years, which provide a greater diversity of options to meet the characteristics and needs of patients with anaphylaxis. Conclusion: There currently are no EAIs with customizable dose and needle length. Although precise personalization of each patient's EAI remains an optimistic future aspiration, careful consideration of all variables when prescribing EAIs can support optimal management of anaphylaxis.
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Affiliation(s)
- Harold Kim
- From the Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Reza Alizadehfar
- Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada, and
| | - David A Fischer
- From the Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Hannah Roberts
- From the Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Bahar Torabi
- Pediatric Allergy and Clinical Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan Waserman
- Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Dreborg S, Walter G, Kim H. International recommendations on epinephrine auto-injector doses often differ from standard weight-based guidance: a review and clinical proposals. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2022; 18:102. [PMID: 36471385 PMCID: PMC9724388 DOI: 10.1186/s13223-022-00736-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 10/25/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND In anaphylaxis, the dosing of injectable epinephrine in medical settings has been arbitrarily recommended to be 0.01 mg/kg of body weight. For ethical reasons, there have been no dose-response studies or double-blind studies performed on patients with active anaphylaxis. Intramuscular delivery of epinephrine has been the standard. Auto-injectors for use in the treatment of anaphylaxis are available in four strengths (0.1, 0.15, 0.3, and 0.5 mg). However, in many countries, only the 0.15 and 0.3 mg strengths are available. Consequently, many adult, heavy patients are prescribed the 0.3 mg dose, which may result in only one-fifth to one-third of the recommended weight-based dose being administered in heavy patients experiencing anaphylaxis. Underdosing may have therefore contributed to mortality in anaphylaxis. OBJECTIVE To review the doses of epinephrine recommended for the treatment of anaphylaxis in the community, and assess whether recommendations should be made to increase dosing for heavy adult patients in hopes of avoiding future deaths from anaphylaxis. METHODS We reviewed multiple national and international recommendations for the dosing of epinephrine. We also reviewed the literature on adverse drug reactions from epinephrine, lethal doses of epinephrine, and epinephrine dose-finding studies. RESULTS The majority of national and regional professional societies and authorities recommend epinephrine delivered by auto-injectors at doses far lower than the generally accepted therapeutic dose of 0.01 mg/kg body weight. Furthermore, we found that the recommendations vary even within regions themselves. CONCLUSIONS We suggest prescribing more appropriate doses of epinephrine auto-injectors based on weight-based recommendations. There may be some exceptions, such as for patients with heart disease. We hypothesize that these recommendations will lead to improved outcomes of anaphylaxis.
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Affiliation(s)
- Sten Dreborg
- Department of Child and Adolescent Allergology, Women's and Children's Health, University of Uppsala, Uppsala, Sweden
| | - Graham Walter
- Department of Medicine, Western University, London, ON, Canada
- Division of Clinical Immunology and Allergy, Western University, London, ON, Canada
| | - Harold Kim
- Department of Medicine, Western University, London, ON, Canada.
- Division of Clinical Immunology and Allergy, Western University, London, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Gaudio FG, Johnson DE, DiLorenzo K, Anderson A, Musi M, Schimelpfenig T, Leemon D, Blair-Smith C, Lemery J. Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis. Wilderness Environ Med 2022; 33:75-91. [PMID: 35120856 DOI: 10.1016/j.wem.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 10/01/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled β agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.
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Affiliation(s)
- Flavio G Gaudio
- Department of Emergency Medicine, New York Presbyterian-Weill Cornell Medicine, New York, NY.
| | | | - Kelly DiLorenzo
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Arian Anderson
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Martin Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | - Drew Leemon
- National Outdoor Leadership School, Lander, WY
| | | | - Jay Lemery
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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Abstract
The key to managing anaphylaxis is early epinephrine administration. This can improve outcomes and prevent progression to severe and fatal anaphylaxis. Delayed or lack of administration of epinephrine is associated with fatal reactions. Positioning in a recumbent supine position, airway management, and intravenous fluids are essential in its management. Antihistamines and glucocorticosteroids should not be prescribed in place of epinephrine. β-adrenergic agonists by inhalation are indicated for bronchospasm associated with anaphylaxis despite optimal epinephrine treatment. Long-term management of anaphylaxis includes the identification and avoidance of triggers; identification of cofactors, such as mast cell disorders; patient, parent, and caregiver education, and interventions to reduce allergen sensitivity, such as the use of venom immunotherapy for Hymenoptera hypersensitivity. Long-term management is covered in other articles. Consultation with an allergist/immunologist is recommended when necessary.
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Affiliation(s)
- Aishwarya Navalpakam
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University College of Medicine, 3950 Beaubien Boulevard, Detroit, MI 48201, USA
| | - Narin Thanaputkaiporn
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University College of Medicine, 3950 Beaubien Boulevard, Detroit, MI 48201, USA
| | - Pavadee Poowuttikul
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University College of Medicine, 3950 Beaubien Boulevard, Detroit, MI 48201, USA.
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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Brown JC, Simons E, Rudders SA. Epinephrine in the Management of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1186-1195. [DOI: 10.1016/j.jaip.2019.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 10/24/2022]
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Parish HG, Morton JR, Brown JC. A systematic review of epinephrine stability and sterility with storage in a syringe. Allergy Asthma Clin Immunol 2019; 15:7. [PMID: 30828350 PMCID: PMC6383228 DOI: 10.1186/s13223-019-0324-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/08/2019] [Indexed: 11/28/2022] Open
Abstract
Background Epinephrine is a lifesaving medication in the treatment of anaphylaxis. Epinephrine auto-injectors are the preferred method of epinephrine administration, but are not universally available or affordable. Little is known about the effects on epinephrine when it is drawn up in advance and stored as prefilled syringes. Objective To study the stability and sterility of epinephrine when stored in syringes. Methods We searched Embase, Medline, and Web of Science in June 2016 for all studies of epinephrine stored in syringes in concentrations between 0.1 and 1 mg/mL that measured epinephrine stability and/or sterility over time, regardless of date published or language. Results Three studies were included, one testing two concentrations of epinephrine. Only one study tested epinephrine 1 mg/mL, the concentration clinically relevant for intramuscular use during anaphylaxis. Neither this study nor the one study testing 0.7 mg/mL epinephrine found significant degradation after 56 and 90 days, respectively. One of the two studies testing epinephrine at a concentration of 0.1 mg/mL found significant degradation by 14 days; the other found no degradation up to 168 days. Two studies tested for bacterial growth, with none detected after 28 and 90 days, respectively. One study tested for fungal growth, with none detected after 90 days. Conclusions Limited evidence suggests that syringes filled with 1 mg/mL epinephrine are stable and sterile for 90 days. More research is needed testing the duration of stability and sterility of prefilled syringes with the 1 mg/mL concentration most commonly used in anaphylaxis, testing more extensively in different storage conditions and across a wider range of marketed syringe brands.
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Affiliation(s)
- Hannah G Parish
- 1Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105 USA
| | - Jacquelyn R Morton
- 1Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105 USA
| | - Julie C Brown
- 1Seattle Children's Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105 USA.,2Department of Pediatrics, Division of Emergency Medicine, University of Washington, Seattle, WA 98195 USA
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Brown JC. Epinephrine, auto-injectors, and anaphylaxis: Challenges of dose, depth, and device. Ann Allergy Asthma Immunol 2018; 121:53-60. [PMID: 29746901 DOI: 10.1016/j.anai.2018.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE This review was undertaken to review epinephrine dosing, site and route of administration, focusing on special populations (patients weighing less than 15 kg, and obese patients); and to discuss storage and delivery of epinephrine in prehospital and hospital settings. DATA SOURCES Review of published literature. STUDY SELECTION Relevance. RESULTS The recommended 0.01-mg/kg (maximum 0.3-0.5 mg) epinephrine dose in anaphylaxis is based on limited pharmacokinetic data in healthy volunteers. No pharmacokinetic or pharmacodynamics studies involving patients in anaphylaxis have been published. When epinephrine auto-injectors (EAIs) are used in infants, the dose increasingly exceeds the recommended dose as weight decreases, although the clinical significance of this is unclear. Limited data indicate that the intramuscular route and lateral thigh site are superior. Ultrasound studies suggest that 0.15 EAI needles may be too long for many patients weighing less than 15 kg, and 0.3 mg EAI needles may be too short for obese patients weighing more than 30 kg. A newly available 0.1 mg EAI has a lower dose and shorter needle better suited to patients weighing 7.5 to 15 kg. In some medical settings, vials and syringes may provide a safe, efficient alternative with substantial cost savings over EAIs. CONCLUSION EAIs should be available in the community with doses and needle depths that meet the needs of all patients. More research on epinephrine pharmacodynamics are needed in children and adults in anaphylaxis, to better delineate what optimal doses should be. Optimizing epinephrine dose and delivery has the potential to improve anaphylaxis outcomes and prevent adverse events.
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Affiliation(s)
- Julie C Brown
- Seattle Children's Hospital and University of Washington, Seattle, Washington.
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11
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Kim H, Dinakar C, McInnis P, Rudin D, Benain X, Daley W, Platz E. Inadequacy of current pediatric epinephrine autoinjector needle length for use in infants and toddlers. Ann Allergy Asthma Immunol 2017; 118:719-725.e1. [PMID: 28483294 DOI: 10.1016/j.anai.2017.03.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/12/2017] [Accepted: 03/28/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Epinephrine injection represents the standard of care for anaphylaxis treatment. It is most effective if delivered intramuscularly, whereas inadvertent intraosseous injection may be harmful. The needle length in current pediatric epinephrine autoinjectors (EAIs) is 12.7 mm; however, the ideal needle length for infants and toddlers weighing less than 15 kg is unknown. OBJECTIVE To determine the skin-to-bone distance (STBD) and skin-to-muscle distance (STMD) at baseline and after simulated EAI application in infants and toddlers (weighing 7.5-15 kg). METHODS Study participants recruited from 2 North American allergy clinics underwent baseline and compression (10-lb pressure) ultrasonography of the anterolateral thigh with a modified ultrasound transducer mimicking the footprint and maximum pressure application of an EAI device. Ultrasound images, with clinical data masked, were analyzed offline for STBD and STMD in short-axis approach. RESULTS Of 53 infants (mean age, 18.9 months; 54.7% male; 81.1% white; mean weight, 11.0 kg), 51 had adequate images for short-axis STBD measurements. In these infants, the mean (SD) baseline STBD was 22.4 (3.8 mm), and the mean (SD) STMD was 7.9 (1.7) mm. With 10-lb compression, the mean (SD) STBD was 13.3 (2.1) mm, and the mean (SD) STMD was 6.3 (1.2) mm. An EAI with a needle length of 12.7 mm applying 10-lb pressure could strike the bone in 43.1% of infants and toddlers in this cohort. CONCLUSION Our data suggest that the optimal EAI needle length for infants and toddlers weighing 7.5 to 15 kg should be shorter than the needle length in currently available pediatric EAIs to avoid accidental intraosseous injections.
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Affiliation(s)
- Harold Kim
- Department of Medicine, Western University, London, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Chitra Dinakar
- Department of Medicine, Stanford University, Stanford, California
| | - Paul McInnis
- Department of Engineering, University of Waterloo, Waterloo, Ontario, Canada
| | - Dan Rudin
- Clinical and Exploratory Pharmacology, Sanofi US, Bridgewater, New Jersey
| | | | - William Daley
- Clinical and Exploratory Pharmacology, Sanofi US, Bridgewater, New Jersey
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Pouessel G, Deschildre A. [Anaphylaxis in children: What pediatricians should know]. Arch Pediatr 2016; 23:1307-1316. [PMID: 27836164 DOI: 10.1016/j.arcped.2016.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/02/2016] [Accepted: 09/14/2016] [Indexed: 11/18/2022]
Abstract
Anaphylaxis is a severe potentially life-threatening allergic emergency that has been increasing over the last two decades, especially in young children. Anaphylaxis deaths remain rare, in particular in children, and their frequency is stable during this period. Food is the main anaphylaxis trigger in children, notably to cow's milk, peanuts, and tree nuts. In infants, the recognition of anaphylaxis may be difficult. Vomiting, urticaria, and laryngeal edema are more frequent at this age. Cardiovascular involvement is rare, most often encountered in adolescence. A history of asthma or atopy, allergy to particular foods such as peanuts and tree nuts, and adolescence are some risk factors for anaphylaxis and more severe reactions. First-line treatment is intramuscular adrenaline for all patients experiencing anaphylaxis. There are no absolute contra-indications. Guidelines for the prescription of the adrenaline auto-injector and for establishing a personalized care project in allergic children at school have recently been updated. Recognition of anaphylaxis and treatment should also be improved.
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Affiliation(s)
- G Pouessel
- Service de pédiatrie, pavillon médicochirurgical de pédiatrie, boulevard Lacordaire, 59056 Roubaix, France; Unité de pneumologie et allergologie pédiatriques, université Lille 2, hôpital Jeanne-de-Flandre, CHRU Lille, 2, avenue Oscar-Lambret, 59037 Lille, France.
| | - A Deschildre
- Unité de pneumologie et allergologie pédiatriques, université Lille 2, hôpital Jeanne-de-Flandre, CHRU Lille, 2, avenue Oscar-Lambret, 59037 Lille, France
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Campbell RL, Bellolio MF, Motosue MS, Sunga KL, Lohse CM, Rudis MI. Autoinjectors Preferred for Intramuscular Epinephrine in Anaphylaxis and Allergic Reactions. West J Emerg Med 2016; 17:775-782. [PMID: 27833688 PMCID: PMC5102607 DOI: 10.5811/westjem.2016.8.30505] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 09/19/2016] [Accepted: 08/29/2016] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Epinephrine is the treatment of choice for anaphylaxis. We surveyed emergency department (ED) healthcare providers regarding two methods of intramuscular (IM) epinephrine administration (autoinjector and manual injection) for the management of anaphylaxis and allergic reactions and identified provider perceptions and preferred method of medication delivery. METHODS This observational study adhered to survey reporting guidelines. It was performed through a Web-based survey completed by healthcare providers at an academic ED. The primary outcomes were assessment of provider perceptions and identification of the preferred IM epinephrine administration method by ED healthcare providers. RESULTS Of 217 ED healthcare providers invited to participate, 172 (79%) completed the survey. Overall, 82% of respondents preferred the autoinjector method of epinephrine administration. Providers rated the autoinjector method more favorably for time required for training, ease of use, convenience, satisfaction with weight-based dosing, risk of dosing errors, and speed of administration (p<0.001 for all comparisons). However, manual injection use was rated more favorably for risk of provider self-injury and patient cost (p<0.001 for both comparisons). Three participants (2%) reported a finger stick injury from an epinephrine autoinjector. CONCLUSION ED healthcare providers preferred the autoinjector method of IM epinephrine administration for the management of anaphylaxis or allergic reactions. Epinephrine autoinjector use may reduce barriers to epinephrine administration for the management of anaphylaxis in the ED.
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Affiliation(s)
| | | | - Megan S. Motosue
- Mayo Clinic, Division of Allergic Diseases, Rochester, Minnesota
| | | | - Christine M. Lohse
- Mayo Clinic, Division of Biomedical Statistics and Informatics, Rochester, Minnesota
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Pouessel G, Deschildre A, Beaudouin E, Birnbaum J, Neukirch C, Meininger C, Leroy S. À qui prescrire un dispositif auto-injectable d’adrénaline ? Position des groupes de travail « Anaphylaxie », « Allergie alimentaire », « Insectes piqueurs » sous l’égide de la Société française d’allergologie. REVUE FRANCAISE D ALLERGOLOGIE 2016. [DOI: 10.1016/j.reval.2016.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bilò MB, Cichocka-Jarosz E, Pumphrey R, Oude-Elberink JN, Lange J, Jakob T, Bonadonna P, Fernandez J, Kosnik M, Helbling A, Mosbech H, Gawlik R, Niedoszytko M, Patella V, Pravettoni V, Rodrigues-Alves R, Sturm GJ, Rueff F. Self-medication of anaphylactic reactions due to Hymenoptera stings-an EAACI Task Force Consensus Statement. Allergy 2016; 71:931-43. [PMID: 27060567 DOI: 10.1111/all.12908] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2016] [Indexed: 11/29/2022]
Abstract
An anaphylactic reaction due to a Hymenoptera sting is a clinical emergency, and patients, their caregivers as well as all healthcare professionals should be familiar with its recognition and acute management. This consensus report has been prepared by a European expert panel of the EAACI Interest Group of Insect Venom Hypersensitivity. It is targeted at allergists, clinical immunologists, internal medicine specialists, pediatricians, general practitioners, emergency department doctors, and any other healthcare professional involved. The aim was to report the scientific evidence on self-medication of anaphylactic reactions due to Hymenoptera stings, to inform healthcare staff about appropriate patient self-management of sting reactions, to propose indications for the prescription of an adrenaline auto-injector (AAI), and to discuss other forms of medication. First-line treatment for Hymenoptera sting anaphylaxis is intramuscular adrenaline. Prescription of AAIs is mandatory in the case of venom-allergic patients who suffer from mast cell diseases or with an elevated baseline serum tryptase level and in untreated patients with a history of a systemic reaction involving at least two different organ systems. AAI prescription should also be considered in other specific situations before, during, and after stopping venom immunotherapy.
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Affiliation(s)
- M. B. Bilò
- Allergy Unit; Department of Internal Medicine; University Hospital; Ancona Italy
| | - E. Cichocka-Jarosz
- Department of Pediatrics; Jagiellonian University Medical College; Krakow Poland
| | - R. Pumphrey
- Immunology; Central Manchester University Hospitals; Manchester UK
| | - J. N. Oude-Elberink
- Department of Allergology; GRIAC Research Institute; University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - J. Lange
- Department of Pediatric Pulmonology and Allergy; Medical University of Warsaw; Warsaw Poland
| | - T. Jakob
- Department of Dermatology and Allergology; Justus Liebig University Gießen; University Medical Center Gießen and Marburg GmbH; Gießen Germany
| | - P. Bonadonna
- Allergy Unit; Azienda Ospedaliera Universitaria Integrata of Verona; Verona Italy
| | - J. Fernandez
- Allergy Service; Department of Clinical Medicine; Alicante University Hospital; UMH; Alicante Spain
| | - M. Kosnik
- University Clinic of Respiratory and Allergic Disease; Golnik Slovenia
| | - A. Helbling
- Division of Allergology; University Clinic of Rheumatology, Immunology and Allergology; University Hospital/Inselspital; Bern Switzerland
| | - H. Mosbech
- Allergy Unit; Department of Dermatology and Allergy; Copenhagen University Hospital Gentofte; Hellerup Denmark
| | - R. Gawlik
- Department of Internal Medicine, Allergy and Clinical Immunology; Silesian University of Medicine; Katowice Poland
| | - M. Niedoszytko
- Department of Allergology; Medical University of Gdansk; Gdansk Poland
| | - V. Patella
- Division and School of Allergy and Clinical Immunology; ASL Salerno and University of Naples Federico II, Naples; Battipaglia Hospital; Salerno Italy
| | - V. Pravettoni
- Clinical Allergy and Immunology Unit; Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy
| | - R. Rodrigues-Alves
- Allergy and Clinical Immunology Division; Divino Espirito Santo Hospital; Ponta Delgada Portugal
| | - G. J. Sturm
- Ambulatory for Allergy and Clinical Immunology; Vienna Austria
- Department of Dermatology; Medical University of Graz; Graz Austria
| | - F. Rueff
- Department of Dermatology and Allergology; Ludwig-Maximilian University; Munich Germany
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Abstract
PURPOSE OF REVIEW Anaphylaxis is a serious allergic reaction that can be life threatening. We will review the most recent evidence regarding the diagnosis, treatment, monitoring, and prevention of anaphylaxis in children. RECENT FINDINGS Histamine and tryptase are not sufficiently accurate for the routine diagnosis of anaphylaxis, so providers should continue to rely on clinical signs. Platelet-activating factor shows some promise in the diagnosis of anaphylaxis. Intramuscular is the best route for epinephrine administration for children of all weights. Glucocorticoids may reduce prolonged hospitalizations for anaphylaxis. Children with anaphylaxis who have resolving symptoms and no history of asthma or previous biphasic reactions may be observed for as few as 3-4 h before emergency department discharge. Early peanut introduction reduces the risk of peanut allergy. SUMMARY Epinephrine remains the mainstay of anaphylaxis treatment, and adjuvant medications should not be used in its place. All patients with anaphylaxis should be prescribed and trained to use an epinephrine autoinjector. Clinically important biphasic reactions are rare. Observation in the emergency department for most anaphylaxis patients is recommended, with the duration determined by risk factors. Admission is reserved for patients with unimproved or worsening symptoms, or prior biphasic reaction.
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Affiliation(s)
- Karen S. Farbman
- Boston Children's Hospital, Division of Emergency Medicine, Boston, MA
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