Prevention of anaphylaxis in healthcare settings

Abstract

In this paper, we review recent evidence on preventing anaphylaxis in healthcare settings and contexts where the risk of developing anaphylaxis is known to be increased. These include investigation units in which patients are undergoing challenge testing, outpatient clinics undertaking immunotherapy and vaccination, inpatient settings in which patients receive antibiotics, non-steroidal anti-inflammatory drugs, opiates and biological agents and operating theatres in which patients receive general anesthetics. Anaphylaxis may however develop unpredictably in any patient exposed to a wide range of drugs, food and other triggers (e.g., latex, iodinated contrast media and exercise), so it is important that all healthcare professionals and systems have effective, well-rehearsed protocols for risk assessment and management of this allergic emergency. Where available, we consider evidence for the effectiveness of interventions aiming to reduce the risk of developing anaphylaxis.

Keywords::

• anaphylaxis
• emergency
• guidelines
• management
• patient safety
• prevention

Financial & competing interests disclosure

A Sheikh has undertaken advisory work for ALK Abello, Lincoln Medical and ThermoFisher. A Sheikh was a member of the UK Resuscitation Working Party on Anaphylaxis, the World Allergy Organization Special Committee on Anaphylaxis and the European Academy of Allergy and Clinical Immunology Guidelines on Food Allergy and Anaphylaxis Working Group. A Sheikh is the Royal College of General Practitioners Clinical Lead for Allergy. Worth A has received funding to attend conferences and deliver training from ALK Abello, Meda and ThermoFisher. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Anaphylaxis is a medical emergency that may result in death.

• • Although the majority of reactions occur in community settings, many healthcare procedures can trigger episodes of anaphylaxis.

• • All health professionals should be trained in anaphylaxis recognition and management.

• • In terms of patient populations, increased risk is established in those who have experienced previous anaphylaxis and allergic reactions and/or have evidence of allergic sensitization to foods, latex, radiocontrast media and drugs.

• • Most reactions in healthcare environments will occur in the context of administration of treatments–in particular, antibiotics, immunotherapy/desensitization, anesthetics and analgesics, snake and antivenom and biological agents–and investigative procedures that involve allergen testing/challenge, radiocontrast media and latex-based equipment.

• • There is at present very limited robust evidence on which to base decisions on anaphylaxis prevention.

• • That said, this review has highlighted a number of steps that can be taken to try and minimize risk in the context of a range of relevant diagnostic and treatment procedures which, if implemented, should help to reduce the risk of anaphylaxis.

• • Despite these measures, reactions will still on occasion occur; we have therefore also drawn on insights from patient safety science to draw attention to the importance of learning from systems failures and ensuring that any insights gleaned are used as a basis for enhancing the safety of health systems.

• • This is an area where there is a need for considerable research and, given the major challenges in undertaking prevention studies, it is important this work proceeds in a collaborative manner if progress is to be made.