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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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Hubbard JA, Wolfe RC. Perioperative Considerations in Patients With Mast Cell Activation Syndrome. J Perianesth Nurs 2023; 38:357-360. [PMID: 36828701 DOI: 10.1016/j.jopan.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 02/25/2023]
Affiliation(s)
- Julie A Hubbard
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO
| | - Rachel C Wolfe
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO.
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Hendin A, Lanoue D, Syed S. Just the facts: anaphylaxis and its mimics in the emergency department. CAN J EMERG MED 2023; 25:370-373. [PMID: 36964856 DOI: 10.1007/s43678-023-00483-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/04/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Ariel Hendin
- Department of Emergency Medicine, The Ottawa Hospital, Civic Campus, University of Ottawa, Ottawa, ON, Canada.
| | - Derek Lanoue
- Division of Allergy and Immunology, McGill University Health Centre, Montréal, QC, Canada
| | - Shahbaz Syed
- Department of Emergency Medicine, The Ottawa Hospital, Civic Campus, University of Ottawa, Ottawa, ON, Canada
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