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Medline ® Abstracts for References 49,50,54

of 'Anaphylaxis: Emergency treatment'

Use of multiple doses of epinephrine in food-induced anaphylaxis in children.
Järvinen KM, Sicherer SH, Sampson HA, Nowak-Wegrzyn A
J Allergy Clin Immunol. 2008;122(1):133. Epub 2008 Jun 10.
BACKGROUND: Food allergy is the most common cause of anaphylaxis outside the hospital setting.
OBJECTIVE: We sought to determine the rate, circumstances, and risk factors for repeated doses of epinephrine in the treatment of food-induced anaphylaxis in children.
METHODS: Anonymous questionnaires were distributed to families of children with food allergies during allergy outpatient visits to a food allergy referral center. Demographic information, allergy and reaction history, and details regarding the last 2 anaphylactic reactions requiring epinephrine were collected.
RESULTS: A total of 413 questionnaires were analyzed. Seventy-eight children (median, 4.5 years of age; range, 0.5-17.5 years) reported 95 reactions for which epinephrine was administered. Two doses were administered in 12 (13%) and 3 doses in an additional 6 (6%) reactions treated with epinephrine. Peanut, tree nuts, and cow's milk were responsible for>75% of reactions requiring epinephrine. Patients receiving multiple doses of epinephrine more often had asthma (P = .027) than children receiving a single dose. The amount of food ingested or a delay in the initial administration of epinephrine were not risk factors for receiving multiple doses. The second dose of epinephrine was administered by a health care professional in 94% of reactions.
CONCLUSION: In this referral population of children and adolescents with multiple food allergies, 19% of food-induced anaphylactic reactions were treated with more than 1 dose of epinephrine. Prospective studies are necessary to identify risk factors for severe anaphylaxis and to establish rational guidelines for prescribing multiple epinephrine autoinjectors for children with food allergy.
Division of Pediatric Allergy and Immunology and Jaffe Institute for Food Allergy, Mount Sinai School of Medicine, New York, NY 10029-6574, USA. kirsi.jarvinen@mssm.edu
Food-induced anaphylaxis and repeated epinephrine treatments.
Oren E, Banerji A, Clark S, Camargo CA Jr
Ann Allergy Asthma Immunol. 2007;99(5):429.
BACKGROUND: Research on the use of more than 1 dose of epinephrine in the treatment of food-induced anaphylaxis is limited.
OBJECTIVE: To perform a medical record review to examine the frequency of repeated epinephrine treatments in patients presenting with food-induced anaphylaxis to the emergency department (ED).
METHODS: We reviewed 39 medical records of patients who presented with food-induced allergic reactions to the Massachusetts General Hospital ED during a 1-year period. The analysis focused on the timing of the onset of symptoms and on the number of epinephrine treatments given before and during the ED visit.
RESULTS: Of the 39 patients, 34 had an acute food-induced allergic reaction. Nineteen had anaphylaxis. Twelve patients with anaphylaxis (63%; 95% confidence interval, 38%-84%) received at least 1 dose of epinephrine, and 3 (16%; 95% confidence interval, 3%-40%) were given 2 doses. Although statistical analysis was not possible, repeated epinephrine treatment occurred in patients with anaphylaxis to peanut or tree nut and hypotension. There was no apparent association between time from ingestion of the causative agent to epinephrine treatment(s).
CONCLUSIONS: Of patients presenting to the ED with food-induced anaphylaxis, approximately 16% were treated with 2 doses of epinephrine. This study supports the recommendation that patients at risk for food-induced anaphylaxis carry 2 doses of epinephrine. Further study is needed to confirm these results and to expand them to patients who do not present to the ED because that group may have a lower frequency of epinephrine use.
Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA. eoren1@yahoo.com
Predictors of Repeat Epinephrine Administration for Emergency Department Patients with Anaphylaxis.
Campbell RL, Bashore CJ, Lee S, Bellamkonda VR, Li JT, Hagan JB, Lohse CM, Bellolio MF
J Allergy Clin Immunol Pract. 2015 Jul-Aug;3(4):576-84. Epub 2015 May 29.
BACKGROUND: Risk factors that predict which patients with anaphylaxis might require repeat doses of epinephrine are poorly understood.
OBJECTIVE: The objective of this study was to identify risk factors associated with the need for multiple doses of epinephrine during an anaphylactic reaction.
METHODS: Patients were included if they met diagnostic criteria for anaphylaxis on presentation to the emergency department (ED) at our academic medical center between April 2008 and February 2014. Data were collected on allergic history, presenting signs and symptoms, anaphylaxis management, and disposition. Univariable and multivariable analyses were performed to estimate associations between possible risk factors and the need for multiple doses.
RESULTS: Of 582 ED patients with anaphylaxis, 45 (8%) required multiple doses of epinephrine. By multivariable analysis, factors associated with the need for repeat doses were a history of anaphylaxis (odds ratio [OR], 2.5 [95% CI, 1.3-4.7]; P = .005), the presence of flushing or diaphoresis (OR, 2.4 [95% CI, 1.3-4.5]; P = .007), and the presence of dyspnea (OR, 2.2 [95% CI, 1.0-5.0]; P = .046). Patients who received more than 1 dose were more likely to be admitted to the general medical floor (OR, 2.8 [95% CI, 1.1-7.2]; P = .03) or intensive care unit (OR, 7.6 [95% CI, 3.7-15.6]; P<.001).
CONCLUSION: Patients with a history of anaphylaxis, flushing or diaphoresis, or dyspnea may require multiple doses of epinephrine to treat anaphylactic reactions. Patients who require more than 1 dose are more likely to be admitted to the hospital, thus increasing health care resource utilization.
Department of Emergency Medicine, Mayo Clinic, Rochester, Minn. Electronic address: campbell.ronna@mayo.edu.