Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology

Abstract

Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life-threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First-line treatment for anaphylaxis is intramuscular adrenaline. Useful second-line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high-flow oxygen, intravenous fluids, inhaled short-acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto-injector. If an adrenaline auto-injector is prescribed, education on when and how to use the device should be provided. Specialist follow-up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis.

Triggers, risk factors and clinico‐pathological features of urticaria in dogs – a prospective observational study of 24 cases

“…Anaphylaxis is a serious, generalized or systemic, allergic or hypersensitivity reaction with sudden onset (minutes to a few hours) that can be life threatening or even fatal. [8][9][10][11][12] The target organs in humans often include the respiratory tract (70% of episodes) and less frequently the gastrointestinal (GI) organs (30-45% of episodes), heart and vasculature (10-45% of episodes) and central nervous system (CNS) (10-15% of episodes). 8 It is generally agreed that anaphylaxis may occur with or without cutaneous signs, even though these latter signs are frequent and occur in 80-100% of cases.…”

Drug‐induced anaphylaxis in the emergency room

“…4). 1, 31, 32, 33 Early injection of adrenaline for anaphylaxis, defined as injection before ER arrival, can significantly reduce the likelihood of hospital admission, as compared with initial injection after arrival at the ER 34. Although no human studies regarding the timing of treatment for anaphylaxis could be found, analysis of 92 deaths related to anaphylaxis showed that adrenaline was given prior to cardiac arrest in only 22 of the cases (24%) 35.…”

“…Most international anaphylaxis guidelines recommend injection of adrenaline by the intramuscular route in the mid‐anterolateral thigh at a dose of 0.01 mg/kg of a 1:1,000 (1 mg/mL) solution, up to a maximum of 0.5 mg in adults (0.3 mg in children). Depending on the severity of the episode and the response to the initial injection, the dose can be repeated every 5–15 min, as required 1, 31, 33, 36. Intravenous adrenaline is an option in patients with severe hypotension or cardiac arrest unresponsive to intramuscular doses of adrenaline and fluid resuscitation 1.…”

“…International guidelines concur that H1 and H2 antihistamines and glucocorticoids are second‐line31 and even third line33 treatments for anaphylaxis. These medications are not life‐saving and should not be used as initial or sole treatment.…”

“…Patients chronically medicated with β‐blockers and/or angiotensin‐converting enzyme inhibitors are potentially at risk for development of unresponsiveness to adrenaline 42. In such patients, vasopressin,43 methylene blue,44 and glucagon33, 42, 45 might be effective.…”