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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Is adrenaline misused in anaphylaxis treatment? Experience of a large, urban Emergency Department: review of 589 cases.


Objective. Acute allergic reactions are important causes of Emergency Department (ED) admissions. Although the current recommendations for treatment of patients with anaphylaxis are focused on the central role of adrenaline, evidence in support of this therapy is still scarce. We planned a retrospective analysis of all allergic and anaphylactic reactions managed in the ED, to assess adherence to current guidelines and clinical outcomes.

Methods. The study population consisted of all consecutive adult patients admitted to the ED with acute allergic reactions during the year 2013. Overall, the final study population consisted of 589 patients, i.e., 329 women and 260 men (55.9% vs. 44.1%, mean age 43±18 years, range 16-96 years).

Results. Fifty-six patients were diagnosed with anaphylaxis (9.5%), 75 with angioedema (12.7%), 363 with urticaria (61.7%), and 95 with urticaria-angioedema (16.1%). The triggers included drugs (21.9%), foods (15.0%), hymenoptera stings (9.9%), and chemicals (4.4%), whereas a specific cause could not be recognized in nearly half of the cases. Only 5 (8.9%) of 56 patients diagnosed with anaphylaxis received adrenaline and no death or Intensive Care Unit (ICU) admission occurred within one month from the acute allergic episode.

Conclusion. The results of our study suggest that anaphylaxis is widely undertreated with adrenaline in our local ED compared to guidelines and recommendations. Nevertheless, a favorable outcome was recorded for all patients included in the study, even when managed with second- and third-line treatments, as attested by the lack of deaths at 1 month and the very limited number of hospitalizations (3/589; 0.5%), related to comorbidities rather than to treatment failure. The strength of recommendations contained in current guidelines should hence be reconsidered.

Key words: allergy, anaphylaxis, urticaria, angioedema, adrenaline, epinephrine

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Epinephrine induced cardiomyopathy in a child with anaphylaxis


Transient cardiomyopathy is an uncommon occurrence in patients with anaphylaxis. Catecholamine induced direct toxicity is one of the proposed mechanisms. We report a case of cardiomyopathy in a child with anaphylaxis who was treated with multiple doses of epinephrine as well as a continuous infusion of epinephrine. A twenty one month old girl with egg allergy presented to our hospital with anaphylaxis, after multiple doses of epinephrine injections, developed cardiorespiratory dysfunction and required endotracheal intubation and mechanical ventilation. Work up showed depressed cardiac function, which improved with milrinone and furosemide infusions. Conclusion: Epinephrine is the treatment of choice for anaphylaxis however caution should be exercised when administering multiple doses of epinephrine. Myocardial function needs to be assessed in children with persistent hypotension after anaphylaxis and catecholamine-induced cardiomyopathy should be considered in children with anaphylaxis when severe myocardial dysfunction is present.

Key words: anaphylaxis, epinephrine, cardiomyopathy, children

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Epinephrine administration via a laryngeal mask airway: what is the optimal dose?


Background. The aim of this animal study was to clarify the effects of laryngeal mask airway (LMA)-administrated epinephrine and to assess the optimal dose.
Methods. Thirty pigs were anesthetized and intubated with a cuffed tracheal tube (TT) and an LMA. Then they were assigned to one of five groups. The control group received distilled water 10 mL via the TT; the TT group received epinephrine 50 μg/kg via the TT; and the other three groups received two, four or six times the TT dose of epinephrine via the LMA. Heart rate (HR) and arterial pressure were monitored before and after drug administration for 15 minutes.
Results. After epinephrine administration, the LMA-6 and TT groups had elevated systolic, diastolic and mean arterial pressures at 1 min and there was no significant difference between the two groups. In the TT group, these parameters peaked at 2 min then declined rapidly. In the LMA-6 group, they increased more slowly, and then maintained a plateau. The control, LMA-2 and LMA-4 groups failed to display significant persistent (>2 min) hemodynamic changes.
Conclusions. We could not identify an optimal LMA-administrated epinephrine dose. The TT route is suitable when a high peak drug effect is required and the LMA route may be preferable if a persistent plateau effect is desired. Effective LMA administration of drugs may require larger doses than those given via TT.

Keywords: airway, drug delivery, epinephrine, laryngeal mask airway (LMA), tracheal tube

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Vasopressin and epinephrine versus epinephrine in management of patients with cardiac arrest: a meta-analysis


Objective. A combination of vasopressin and epinephrine may be more effective than epinephrine alone in cardiopulmonary resuscitation (CPR), but evidence is lacking to make clinical recommendations. This meta-analysis compares the efficacy of vasopressin and epinephrine used together versus epinephrine alone in cardiac arrest (CA).

Methods. We searched MEDLINE and EMBASE for randomized trials comparing the efficacy of vasopressin and epinephrine versus epinephrine alone in adults with cardiac arrest. The primary outcome was the return of spontaneous circulation (ROSC) and the survival rate on admission and discharge .We also analyzed ROSC in subgroups of patients presenting with different arrest rhythms, such as asystole, pulseless electrical activity (PEA), ventricular fibrillation (VF).

Results. We analyzed 6 randomized trials out of 485 articles. We did not find evidence supporting the superiority of vasopressin and epinephrine used in combination, except for the survival rate at 24h 2.99 95% CI(1.43,6.28). No evidence supports the conclusion that vasopressin combined with epinephrine is better than epinephrine alone for ROSC, even amongst subgroups of patients.

Conclusion. This systematic review of the efficacy of vasopressin and epinephrine use found that its combined use is better for 24h survival rate but only in one study which included 122 patients. Further investigation will be needed to support the use of this combination for cardiac arrest management.


Key words: cardiopulmonary resuscitation, meta-analysis, epinephrine, vasopressin

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Early morning upper airway discomfort and appearance on two X ray films


We reported a case of reversible but severe upper airway stenosis. The patient complained of only slight discomfort in her throat after waking: she had a history of allergic reaction to contrast medium. Her X ray films showed severe edema in her pharynx. Epiglottitis was diagnosed and we started treatment. It should not be forgotten, that even mild symptoms, such as discomfort in the throat, could indicate the existence of severe epiglottitis.

Key words: airway discomfort, airway stenosis, edema, epinephrine, ste-roids, epiglottitis


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