Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock

Abstract

Based on this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. Although there is a need for randomized, double-blind, placebo-controlled clinical trials of high methodological quality in order to define the true extent of benefits from the administration of adrenaline in anaphylaxis, such trials are unlikely to be performed in individuals with anaphylaxis. Indeed, they might be unethical because prompt treatment with adrenaline is deemed to be critically important for survival in anaphylaxis. Also, such studies would be difficult to conduct because anaphylactic episodes usually occur without warning, often in a non-medical setting, and differ in severity both among individuals and from one episode to another in the same individual. Consequently, obtaining baseline measurements and frequent timed measurements might be difficult, or impossible, to obtain. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular (i.m.) injection should still be regarded as first-line treatment for the management of anaphylaxis.

Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review

“…A clear statement should be made to this effect in anaphylaxis guidelines (50). Although there is little direct evidence of harm associated with use of glucocorticoids, there is, as noted previously, persistent evidence that glucocorticoids are often inappropriately used as first-line agents in place of adrenaline, which is more likely to prove lifesaving (62). Consideration, therefore, needs to be given to conducting a RCT.…”

Vasopressor and Inotrope Use in Canadian Emergency Departments: Evidence Based Consensus Guidelines

“…A recent Cochrane review on the use of epinephrine for the treatment of anaphylaxis did not find any studies suitable for analysis. 86 A cohort study that analyzed the safety of an epinephrine infusion in patients with anaphylactic shock did not demonstrate any significant adverse effects. 87 Studies in animals have demonstrated potential benefit with the use of phenylephrine, norepinephrine, vasopressin and methylene blue in animal models of anaphylactic shock.…”

The Use of Epinephrine for Out-of-Hospital Treatment of Anaphylaxis: Resource Document for the National Association of EMS Physicians Position Statement

“…5,[11][12][13][14][15][16] Because most cases of anaphylaxis occur in the out-of-hospital environment, it is imperative that EMS providers have the capability to administer epinephrine in a timely fashion. 5,7,11,17 Delayed administration of epinephrine is associated with increased morbidity and mortality, 13,15,[17][18][19] underscoring the importance for prehospital personnel to initiate treatment with epinephrine to patients presenting with anaphylaxis.…”

“…Many health care providers are hesitant to provide epinephrine to anaphylaxis patients out of concern for potential adverse effects, even though there are no absolute contraindications to the use of epinephrine for anaphylaxis. 2,5,14,16,27 There are indeed case reports of fatal cardiac arrhythmias and acute myocardial infarctions, among other cardiovascular and neurologic complications, in patients who received epinephrine during anaphylaxis. 17 However, these cases tend to occur in older patients with preexisting cardiovascular disease.…”