The Resuscitation Council UK has updated its Guideline for healthcare providers on the Emergency treatment of anaphylaxis. As part of this process, an evidence review was undertaken by the Guideline Working Group, using an internationally-accepted approach for adoption, adaptation, and de novo guideline development based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence to decision (EtD) framework, referred to as GRADE-ADOLOPMENT. A number of significant changes have been made, which will be reflected in the updated Guideline.These include: emphasis on repeating intramuscular adrenaline doses after 5 min if symptoms of anaphylaxis do not resolve; corticosteroids (e.g. hydrocortisone) no longer being routinely recommended for the emergency treatment of anaphylaxis; interventions for reactions which are refractory to initial treatment with adrenaline; a recommendation against the use of antihistamines for the acute management of anaphylaxis; and guidance relating to the duration of observation following anaphylaxis, and timing of discharge.
During a prospective 10-week assessment period, 3238 children aged 1-16 years presented with acute wheeze to Paediatric Emergency Research in the UK and Ireland centres. 110 (3.3%) received intravenous bronchodilators. Intravenous magnesium sulfate (MgSO 4 ) was used in 67 (60.9%), salbutamol in 61 (55.5%) and aminophylline in 52 (47.3%) of cases. In 35 cases (31.8%), two drugs were used together, and in 18 cases (16.4%), all three drugs were administered. When used sequentially the most common order was salbutamol, then MgSO 4 , then aminophylline. Overall, 30 different intravenous treatment regimens were used varying in drugs, dose, rate and duration.
There is no established definition for refractory anaphylaxis. The European Anaphylaxis Registry use a definition of "anaphylaxis which, despite treatment with at least two doses of minimum 300 μg adrenaline, does not achieve normalization" of symptoms. 1 A US-based panel recently proposed a reaction which "must be treated with 3+ appropriate doses of epinephrine (or initiation of an intravenous epinephrine infusion)" 2 -a definition which does not specifically refer to treatment response, although this is implied. The Resuscitation Council UK (RCUK) recently updated its guideline on the emergency treatment of anaphylaxis, defining refractory anaphylaxis as a reaction "requiring ongoing treatment despite two (appropriate) doses of intramuscular adrenaline" and proposes an algorithm to facilitate management (Figure 1). 3Refractory anaphylaxis is rare: the European Registry reported a rate of 0.37% of all anaphylaxis cases reported in the registry, with
There are approximately 20-30 deaths reported each year due to anaphylaxis in the UK, but this may be a significant underestimate; approximately 10 anaphylaxis deaths each year are due to foods, and another 10 due to perioperative anaphylaxis. 6 The most common triggers are food, drugs and venom. 4 Food is the most common trigger in young people: teenagers and adults up to the age of 30 years appear to be at greatest risk of fatal food-induced reactions. 4,5 In contrast, the rate of druginduced anaphylaxis is highest in the elderly, probably due to the combination of comorbidities (such as cardiovascular disease) and polypharmacy (including beta-blockers and angiotensinconverting-enzyme (ACE) inhibitors). 4,7 The diagnosis is supported if there is exposure to a known trigger, however, in up to 30% of cases, there may be no obvious trigger ('idiopathic' or 'spontaneous' anaphylaxis). The characteristics of anaphylaxis to the most common causes are shown in Table 1. 1,8 Anaphylaxis is a clinical diagnosis that lies along a spectrum of severity of allergic symptoms (Fig 1 ), and no symptom is entirely specific for the diagnosis.
Sexual health is described by the World Health Organization as a basic human right. Clinicians may struggle to accept that adolescents with life-limiting illnesses may want to talk about sex, and this study has highlighted it as a topic that is generally ignored. Health professionals should include sexual health in routine palliative assessments. Adolescents with life-limiting illnesses should not be denied the right to holistic health care.
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