Medline ® Abstracts for References 37,38
of 'Anaphylaxis: Emergency treatment'
Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine.
Campbell RL, Bellolio MF, Knutson BD, Bellamkonda VR, Fedko MG, Nestler DM, Hess EP
J Allergy Clin Immunol Pract. 2015 Jan;3(1):76-80. Epub 2014 Aug 29.
BACKGROUND: Epinephrine is the drug of choice for the management of anaphylaxis, and fatal anaphylaxis is associated with delayed epinephrine administration. Data on adverse cardiovascular (CV) complications and epinephrine overdose are limited.
OBJECTIVE: To compare rates of CV adverse events and epinephrine overdoses associated with anaphylaxis management between various routes of epinephrine administration among patients with anaphylaxis in the emergency department.
METHODS: This was an observational cohort study from April 2008 to July 2012. Patients in the emergency department who met diagnostic criteria for anaphylaxis were included. We collected demographics; route of epinephrine administration; trigger; overdose; and adverse CV events, including arrhythmia, cardiac ischemia, stroke, angina, and hypertension.
RESULTS: The study cohort included 573 patients, of whom, 301 (57.6%) received at least 1 dose of epinephrine. A total of 362 doses of epinephrine were administered to 301 patients: 67.7% intramuscular (IM) autoinjector, 19.6% IM injection, 8.3% subcutaneous injection, 3.3% intravenous (IV) bolus, and 1.1% IV continuous infusion. There were 8 CV adverse events and 4 overdoses with 8 different patients. All the overdoses occurred when epinephrine was administered IV bolus. Adverse CV events were associated with 3 of 30 doses of IV bolus epinephrine compared with 4 of 316 doses of IM epinephrine (10% vs 1.3%; odds ratio 8.7 [95% CI, 1.8-40.7], P = .006). Similarly, overdose occurred with 4 of 30 doses of IV bolus epinephrine compared with 0 of 316 doses of IM epinephrine (13.3% vs 0%; odds ratio 61.3 [95% CI, 7.5 to infinity], P<.001).
CONCLUSION: The risk of overdose and adverse CV events is significantly higher with IV bolus epinephrine administration. Analysis of the data supports the safety of IM epinephrine and a need for extreme caution and further education about IV bolus epinephrine in anaphylaxis.
Department of Emergency Medicine, Mayo Clinic, Rochester, Minn. Electronic address: email@example.com.
Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications.
Kawano T, Scheuermeyer FX, Stenstrom R, Rowe BH, Grafstein E, Grunau B
BACKGROUND: There is little data describing the differences in epinephrine (epi) administration and cardiac complications among older and younger patients with anaphylaxis.
METHODS: This retrospective cohort study was conducted at two urban emergency departments (ED) over a 5 year-period, and included adults who met a pre-specified criteria for anaphylaxis. Patients≥50years of age were defined as "older". Univariate logistic regression was performed to compare the difference in frequency of epi administration between the "older" and "younger" groups. Among those who received epi, the proportion of patients who received doses exceeding the recommended maximum and who had pre-specified cardiovascular complications were compared between the two groups, stratified further by route of administration.
RESULTS: Of 2995 allergy-related visits, 492 met criteria for anaphylaxis, including 122 (24.8%) older patients. Older patients were less likely to receive epi injection (36.1% vs. 60.5%). Ofthose who received epi, older patients were more likely to receive excessive dose of epi (7/44, 15.9% vs 2/225, 0.9%, unadjusted OR 20.7, 95% CI 3.8-211.7). Four (4/44, 9.1%) older patients experienced cardiovascular complications, compared to 1/225 (0.4%) in the younger group (unadjusted OR 22.4, 95% CI 2.1-1129.8). When examining only intra-muscular epinephrine, 1/31 older patients had cardiac complications, compared to 1/186 in the younger group.
CONCLUSION: Older patients with anaphylaxis were less likely to receive epi injection. Intramuscular epi appears safe in this population; however, the use of intravenous epi should be avoided in older patients due to the potential of developing serious cardiac complications.
Department of Emergency Medicine, St. Paul's Hospital, Vancouver, BC, Canada; Department of Emergency Medicine, University of Fukui Hospital, Fukui Prefecture, Japan. Electronic address: Takahisa.Kawano@ubc.ca.