Comparison of the efficacy of continuous intravenous infusion versus intramuscular injection of epinephrine for initial anaphylaxis treatment

Abstract

Aim Continuous intravenous (CIV) infusion of epinephrine for the treatment of anaphylaxis may be required if symptoms do not improve after intramuscular (IM) injection. As CIV infusion permits precise dose adjustment, we compared treatment course and adverse events following CIV infusion and IM injection of epinephrine for the management of anaphylaxis. Methods Medical records of patients, who were treated for anaphylaxis with epinephrine, were 18 years or older, and were admitted to our department from April 2005 to March 2016, were retrospectively reviewed. The cases were categorized as CIV infusion or IM injection, and treatment course and outcomes were compared between the two groups. Results Of the 142 eligible cases, there were 78 in the CIV infusion group and 64 in the IM injection group. The CIV infusion group had lower systolic blood pressure, more respiratory symptoms, and higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, but required a lower total dose of epinephrine, had fewer adverse events after epinephrine administration, and showed lower incidence of biphasic reactions. In addition, compared with the IM injection group, time to administration of epinephrine was significantly longer ( P < 0.001), but time to resolution of symptoms, both from contact and epinephrine administration, was significantly shorter ( P < 0.01 and P = 0.03, respectively). Conclusion Continuous intravenous infusion of epinephrine for the treatment of anaphylaxis may be safe, has fewer adverse events, improves symptoms, and is relatively easy to administer under ready conditions. CIV infusion of epinephrine may also reduce the incidence of biphasic reactions.

Management of Refractory Anaphylaxis: An Overview of Current Guidelines

“…This recommendation is based on evidence from the management of other forms of distributive shock, case reports of severe human anaphylaxis and animal models of severe anaphylaxis [39, 40]. Low‐dose intravenous adrenaline infusion is more effective than IV bolus dosing and resulted in a lower total dose requirement and a favourable safety profile [39–41]. However, there is wide variation in the doses recommend for adrenaline bolus and infusion in guidelines with IV infusion dosing (Tables 2 and 3).…”

“…France, (SFMU/SFA/GFRUP) [25] IM, 10 μg/kg (maximum 0. IM (IV in the perioperative setting), every 5 min of needed IV infusion, starting 5-10 μg/ kg/h (0.08-0.17 μg/kg/min), titrate according to the clinical response (Continues) in a lower total dose requirement and a favourable safety profile [39][40][41]. However, there is wide variation in the doses recommend for adrenaline bolus and infusion in guidelines with IV infusion dosing (Tables 2 and 3).…”

Emergency treatment of peri‐operative anaphylaxis: Resuscitation Council UK algorithm for anaesthetists

“…Low-dose intravenous adrenaline infusions were more effective than bolus dosing and were associated with a lower total dose requirement, lower incidence of biphasic reactions and a favourable safety profile [20][21][22]. For this reason and consistent with international guidelines, the RCUK peri-operative algorithm recommends starting a lowdose intravenous adrenaline infusion if the initial response to intravenous bolus adrenaline is suboptimal [1,23,24].…”

“…Data from human case series and animal models of anaphylactic shock show that bolus doses of adrenaline (irrespective of using the intravenous, intramuscular or subcutaneous route) have only a limited effect on haemodynamic recovery [20, 21]. Low‐dose intravenous adrenaline infusions were more effective than bolus dosing and were associated with a lower total dose requirement, lower incidence of biphasic reactions and a favourable safety profile [20–22]. For this reason and consistent with international guidelines, the RCUK peri‐operative algorithm recommends starting a low‐dose intravenous adrenaline infusion if the initial response to intravenous bolus adrenaline is suboptimal [1, 23, 24].…”