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Medline ® Abstracts for References 10,12-15,18,43

of 'Anaphylaxis: Emergency treatment'

10
TI
Epinephrine and its use in anaphylaxis: current issues.
AU
Simons KJ, Simons FE
SO
Curr Opin Allergy Clin Immunol. 2010;10(4):354.
 
PURPOSE OF REVIEW: Epinephrine is a life-saving medication in the treatment of anaphylaxis, in which it has multiple beneficial pharmacologic effects. Here, we examine the evidence base for its primary role in the treatment of anaphylaxis episodes in community settings.
RECENT FINDINGS: We review the practical pharmacology of epinephrine in anaphylaxis, its intrinsic limitations, and the pros and cons of different routes of administration. We provide a new perspective on the adverse effects of epinephrine, including its cardiac effects. We describe the evidence base for the use of epinephrine in anaphylaxis. We discuss the role of epinephrine auto-injectors for treatment of anaphylaxis in community settings, including identification of patients who need an auto-injector prescription, current use of auto-injectors, and advances in auto-injector design. We list reasons why physicians fail to prescribe epinephrine auto-injectors for patients with anaphylaxis, and reasons why patients fail to self-inject epinephrine in anaphylaxis. We emphasize the primary role of epinephrine in the context of emergency preparedness for anaphylaxis in the community.
SUMMARY: Epinephrine is the medication of choice in the first-aid treatment of anaphylaxis in the community. For ethical reasons, it is not possible to conduct randomized, placebo-controlled trials of epinephrine in anaphylaxis; however, continued efforts are needed towards improving the evidence base for epinephrine injection in this potentially fatal disease.
AD
Faculty of Pharmacy and Department of Pediatrics&Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
PMID
12
TI
Adrenaline for the treatment of anaphylaxis: cochrane systematic review.
AU
Sheikh A, Shehata YA, Brown SG, Simons FE
SO
Allergy. 2009;64(2):204.
 
BACKGROUND: Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis.
OBJECTIVES: To assess the benefits and harms of adrenaline in the treatment of anaphylaxis.
METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://www.clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/ and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion. Two authors independently assessed articles for inclusion.
RESULTS: We found no studies that satisfied the inclusion criteria.
CONCLUSIONS: On the basis of this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular injection should still be regarded as first-line treatment for the management of anaphylaxis.
AD
Allergy&Respiratory Research Group, Division of Community Health Sciences: GP Section, The University of Edinburgh, Edinburgh, UK.
PMID
13
TI
Emergency treatment of anaphylaxis.
AU
Simons FE
SO
BMJ. 2008;336(7654):1141.
 
AD
PMID
14
TI
Adrenaline in the treatment of anaphylaxis: what is the evidence?
AU
McLean-Tooke AP, Bethune CA, Fay AC, Spickett GP
SO
BMJ. 2003;327(7427):1332.
 
AD
Regional Department of Immunology and Allergy, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP. andrew.mclean-tooke@nuth.northy.nhs.uk
PMID
15
TI
Pharmacologic treatment of anaphylaxis: can the evidence base be strengthened?
AU
Simons FE
SO
Curr Opin Allergy Clin Immunol. 2010;10(4):384.
 
PURPOSE OF REVIEW: To evaluate the evidence base for the pharmacologic treatment of anaphylaxis.
RECENT FINDINGS: In this review, we focus on four classes of medications (the alpha/beta-agonist epinephrine (adrenaline), H1-antihistamines, H2-antihistamines, and glucocorticoids) that are used in healthcare settings for the initial treatment of anaphylaxis. Epinephrine and many H1-antihistamines and glucocorticoids were introduced before the era of randomized controlled trials and before the era of evidence-based medicine. In anaphylaxis, no randomized controlled trials that are free from methodological problems and meet current standards have been performed with these medications, or with H2-antihistamines. The evidence base for epinephrine injection is stronger than the evidence base for use of other medications in anaphylaxis. Guidelines unanimously recommend prompt injection of epinephrine as the life-saving first-line medication in anaphylaxis; however, they differ in their recommendations for H1-antihistamines, H2-antihistamines, and glucocorticoids. Epinephrine is the only medication that is universally available for anaphylaxis treatment in healthcare settings worldwide. Paradoxically, it is underused in anaphylaxis treatment.
SUMMARY: For ethical reasons, there should never be a placebo-controlled trial of epinephrine in anaphylaxis. We discuss why the possibility of conducting randomized placebo-controlled trials with H1-antihistamines, H2-antihistamines, and particularly with glucocorticoids in anaphylaxis should be considered in order to improve the evidence base for treatment and guide clinical decision-making. We also describe the precautions that will be needed if randomized controlled trials are conducted in anaphylaxis.
AD
Department of Pediatrics&Child Health, Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. lmcniven@hsc.mb.ca
PMID
18
TI
First-aid treatment of anaphylaxis to food: focus on epinephrine.
AU
Simons FE
SO
J Allergy Clin Immunol. 2004;113(5):837.
 
Avoiding food triggers for anaphylactic reactions (severe acute systemic allergic reactions) is easier said than done. Most episodes of anaphylaxis to food occur unexpectedly in the community in the absence of a health care professional. All individuals at risk should therefore have an emergency action plan in place. The cornerstone of first-aid treatment of anaphylaxis is epinephrine injected intramuscularly in the vastus lateralis muscle (lateral aspect of the thigh). In this review, we focus on epinephrine. We examine a therapeutic dilemma: the issue of epinephrine dose selection in an individual for whom no optimal fixed-dose auto-injector formulation exists, and a therapeutic controversy: the issue of epinephrine injection versus an oral H1-antihistamine in anaphylaxis episodes that appear to be mild. The pharmaceutical industry could address the first of these issues by providing a wider range of epinephrine fixed doses in easy-to-use auto-injectors, or by providing adjustable epinephrine doses in auto-injectors. The second issue could be addressed in part by development of alternative routes of epinephrine administration for the first-aid, out-of-hospital treatment of anaphylaxis.
AD
Section of Allergy and Clinical Immunology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada R3A 1R9. lmcniven@hsc.mb.ca
PMID
43
TI
Epinephrine auto-injectors: is needle length adequate for delivery of epinephrine intramuscularly?
AU
Stecher D, Bulloch B, Sales J, Schaefer C, Keahey L
SO
Pediatrics. 2009;124(1):65.
 
OBJECTIVE: Studies show that intramuscular epinephrine results in peak plasma concentrations of epinephrine faster than the subcutaneous route, and therefore, epinephrine is recommended to be administered intramuscularly. The objective of this study was to determine if the needle length on epinephrine auto-injectors is adequate to deliver epinephrine intramuscularly in children.
METHODS: Patients between the ages of 1 and 12 years who presented to a children's hospital were enrolled in the study. Ultrasound was used to determine the depth from the skin to the vastus lateralis muscle. The patient's body mass index was recorded. The data were analyzed using simple descriptive statistics, and logistic regression was used to identify variables that might predict whether or not the needle length was exceeded.
RESULTS: A total of 256 children were enrolled. Of these, 158 children weighed less than 30 kilograms and would be prescribed the 0.15 mg epinephrine auto-injector. Nineteen of these children (12%) had a skin to muscle surface distance of>(1/2)'' and would not receive epinephrine intramuscularly from current auto-injectors. There were 98 children weighing>or=30 kilograms who would receive the 0.3 mg epinephrine auto-injector. Of these 98 children, a total of 29 (30%) had a skin to muscle surface distance of>(5/8)'' and would not receive epinephrine intramuscularly.
CONCLUSION: The needle on epinephrine auto-injectors is not long enough to reach the muscle in a significant number of children. Increasing the needle length on the auto-injectors would increase the likelihood that more children receive epinephrine by the recommended intramuscular route.
AD
Department of Emergency Medicine, Phoenix Children's Hospital, Phoenix, Arizona 85016, USA. dstecher@phoenixchildrens.com
PMID