Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities

Figures & data

Table

Anaphylaxis is very likely when any one of these 3 criteria are met:

Acute onset (within minutes to 3 hours) of rapidly progressive symptoms involving the skin, mucosal tissue, or both (examples include: generalized hives, pruritus, flushing, swollen lips or tongue) and at least one of the following:

• Respiratory symptoms (dyspnea, wheezing, stridor)

• Hypotension or associated symptoms of end-organ dysfunction (syncope, collapse)

Two or more of the following that occur rapidly after likely exposure to an allergen (within minutes to 3 hours):

• Skin-mucosal involvement (generalized hives, pruritis, flushing, swollen lips or tongue)

• Respiratory symptoms (dyspnea, wheezing, stridor)

• Hypotension or associated symptoms of end-organ dysfunction (syncope, collapse)

• Gastrointestinal symptoms (vomiting, crampy abdominal pain)

Reduced blood pressure after exposure to known allergen for that patient (within minutes to 3 hours)

• This scenario most often involves a patient with known environmental allergies who received an allergen immunotherapy subcutaneous injection immediately prior

Table

• Only 8% of patients diagnosed with drug-induced anaphylaxis in the ED were given epinephrine and only 18% of this population were evaluated by an allergist/immunologist in the 1 year following their reaction.^Citation31

• Implementation of an anaphylaxis order set increased the rate of epinephrine administration in the ED by ~20%.^Citation45

• The NIAID 2006 guidelines for the treatment of anaphylaxis have improved the treatment of management of anaphylaxis with one pediatric ED showing a significant increase in the rate of epinephrine use via the IM route from 6% to 46%. However, only 61% of patients received EAIs upon discharge with no significant change with implementation of the guidelines. There was a significant increase in allergy referrals; however, still, only 48% of patients received referrals post guideline.^Citation28

• In adult patients seen in the ED, drugs are the most common cause of anaphylaxis and several studies demonstrate that less than half of patients diagnosed with anaphylaxis receive epinephrine.^Citation29

• A retrospective chart review of pediatric patients diagnosed with anaphylaxis in the ED showed that only 56% of patients received IM epinephrine and 63% of these patients received a prescription for an EAI. Referral to an allergist was made in only 33% of cases.^Citation33

• While physicians might assume that epinephrine injection is a cause for increased patient stress, a recent study demonstrated that in patients experiencing anaphylaxis, epinephrine use was actually associated with an increased quality of life.^Citation40

• While there is no one specific diagnostic test to identify anaphylaxis, The NIAID/FAAN criteria were validated in the ED to have a sensitivity of 96.7% and a specificity of 82.4%.^Citation32

• Only 38% of patients suspected of having anaphylaxis in the ED had documented follow-up by an allergist, and 35% of these patients had an alteration in the diagnosis and/or trigger of anaphylaxis.^Citation49

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