Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis

Contributors, Workgroup; Reviewers, Joint Task Force on Practice Parameters

doi:10.1016/j.jaci.2020.01.017

Cited by 492 publications

(589 citation statements)

References 249 publications

(464 reference statements)

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“…Currently, the recommendation is the use of intramuscular (IM) epinephrine with repetitive dosing every 5 to 15 minutes depending on response. Additionally, in case the blood pressure does not improve after multiple dosing, an intravenous (IV) infusion is recommended [2,4].…”

Section: Introductionmentioning

confidence: 99%

Physicians’ knowledge regarding epinephrine underuse in anaphylaxis

Pimentel-Hayashi

Rodríguez

Moreno-Laflor

et al. 2020

Asia Pacific Allergy

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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.

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Section: Introductionmentioning

confidence: 99%

Physicians’ knowledge regarding epinephrine underuse in anaphylaxis

Pimentel-Hayashi

Rodríguez

Moreno-Laflor

et al. 2020

Asia Pacific Allergy

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“…The most common presentation is a localized reaction and is typically seen in individuals with few stings and without hypersensitization to the venom. Individuals may also present with allergic systemic symptoms ranging from mild urticarial reactions to anaphylaxis after only a single sting [8]. A third presentation associated with multiple bee stings is massive envenomation that results in systemic toxicity with multi-organ failure.…”

Section: Discussionmentioning

confidence: 99%

A Case Report on Rhabdomyolysis After Multiple Bee Stings

Constantino

Pawlukiewicz

Spear

2020

Cureus

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Envenoming syndrome is an uncommon condition associated with significant morbidity and mortality following multiple Hymenoptera stings. We review the case of a 90-year-old male who presented after receiving greater than 100 bee stings and was found to have rhabdomyolysis with concomitant acute kidney injury. Physicians should consider envenoming syndrome in all patients presenting with greater than 50 bee stings, despite hemodynamically stability upon initial presentation.

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“…This could be proved by the radiology nurse who examined this patient and confirmed no symptoms before and just after the contrast-enhanced CT. Early recognition and treatment can improve the outcomes in patients with anaphylactic shock to contrast media, 15,16 and even a few minutes delay can lead to death. 17 Thus, we consider that this rapid IVC collapse could be an indicator of anaphylactic shock for early recognition, similar to the collapsed IVC sign in patients with trauma, [7][8][9] although there are many barriers to using this finding in clinical settings, such as a busy emergency department or critical situations.…”

Section: Discussionmentioning

confidence: 99%

Rapid collapse of the inferior vena cava in a patient with cardiac arrest induced by anaphylactic shock after iodinated contrast medium injection

2020

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Anaphylactic shock to contrast media can progress to cardiac arrest despite appropriate treatment. During anaphylactic shock to contrast media, rapid vasodilation and a massive fluid shift can occur. Here we report a patient who developed cardiac arrest induced by anaphylactic shock to iodinated contrast medium and exhibited rapid collapse of the inferior vena cava (IVC) on enhanced abdominal computed tomography (CT) images. The patient underwent postsurgical unenhanced and contrast‐enhanced abdominal CT follow‐up of cecum cancer. She had neither allergy nor medical history except for the cancer. She did not complain of any symptoms immediately after completion of the CT. However, she developed anaphylactic shock and pulseless electrical activity cardiac arrest only 2 minutes after finishing the CT despite appropriate treatment. Emergency physicians successfully treated the patient using advanced life support and targeted temperature management. She recovered with good overall and cerebral performance (Overall Performance Category (OPC) 1 and Cerebral Performance Category (CPC) 1). On the contrast‐enhanced CT images, she exhibited rapid collapse of the IVC, although it was normal on the unenhanced CT images. The collapsed IVC is a good indicator of hypovolemia in patients with trauma. In this case, we considered that rapid vasodilation and a massive volume shift might have caused the collapsed IVC. This finding suggests the importance of aggressive volume resuscitation as well as epinephrine injection in patients with anaphylactic shock to contrast media. Furthermore, this finding occurred before the onset of clinical symptoms, and there is a possibility that it could be used as an indicator of anaphylactic shock to contrast media.

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Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis

Cited by 492 publications

References 249 publications

Physicians’ knowledge regarding epinephrine underuse in anaphylaxis

Physicians’ knowledge regarding epinephrine underuse in anaphylaxis

A Case Report on Rhabdomyolysis After Multiple Bee Stings

Rapid collapse of the inferior vena cava in a patient with cardiac arrest induced by anaphylactic shock after iodinated contrast medium injection

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