Article Data

  • Views 1104
  • Dowloads 150

Original Research

Open Access

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

  • GIANFRANCO CERVELLIN1
  • FABIO SCHIROSA1
  • ERMINIA RIDOLO2
  • GIUSEPPE LIPPI3
  • TIZIANA MESCHI2

1Emergency Department, Academic Hospital of Parma, Parma, Italy

2Department of Clinical and Experimental Medicine, Postgraduate School of Emergency Medicine, University of Parma, Parma, Italy

3Laboratory of Clinical Chemistry and Hematology, Academic Hospital of Parma, Parma, Italy

DOI: 10.22514/SV111.052016.6 Vol.11,Issue 1,May 2016 pp.90-102

Published: 02 May 2016

*Corresponding Author(s): GIANFRANCO CERVELLIN E-mail: gianfranco.cervellin@gmail.com; gcervellin@ao.pr.it

Abstract

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.

Keywords

allergy, anaphylaxis, urticaria, angioedema, adrenaline, epinephrine

Cite and Share

GIANFRANCO CERVELLIN,FABIO SCHIROSA,ERMINIA RIDOLO,GIUSEPPE LIPPI,TIZIANA MESCHI. Is adrenaline misused in anaphylaxis treatment? Experience of a large, urban Emergency Department: review of 589 cases.. Signa Vitae. 2016. 11(1);90-102.

References

1. Ewan PW. Anaphylaxis. Br Med J 1998;316:1442-5.

2. Estelle F, Simons R. Anaphylaxis. J Allergy Clin Immunol 2010;125:S161-81.

3. Kaplan AP. Urticaria and angioedema. In: Adkinson NF, Bochner BS, BusseWW, et al. editors. Middleton’s Allergy: Principles and Practice. 7th ed. St Louis (MO): Mosby; 2009. p. 1063.

4. Kaplan AP, Greaves MW. Angioedema. J Am Acad Dermatol

2005;53:373-88.

5. Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, et al. Second symposium on the definition and management of anaphylaxis: summary report – Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006;117:391-7.

6. Lieberman P, Camargo CA Jr, Bohlke K, Jick H, Miller RL, Sheikh A, et al. Epidemiology of anaphylaxis: findings of the American College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group. Ann Allergy Asthma Immunol 2006;97:596-602.

7. Clark S, Gaeta TJ, Kamarthi GS, Camargo CA. ICD-9-CM coding of emergency department visits for food and insect sting allergy. Ann Epidemiol 2006;16:696-700.

8. Gaeta TJ, Clark S, Pelletier AJ, Camargo CA. National study of US emergency department visits for acute allergic reactions, 1993 to 2004. Ann Allergy Asthma Immunol 2007;98:360-5.

9. Kemp SF, Lockey RF, Simons FER, on behalf of the World Allergy Organization ad hoc Committee on Epinephrine in Anaphylaxis. Position paper. Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization. Allergy 2008:63:1061-70.

10. Muraro A, Roberts G, Worm M, Bilò MB, Brockow K, Fernàndez Rivas M, et al. on behalf of the EAACI Food Allergy and Anaphylaxis Guidelines Group. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy 2014;69:1026-45.

11. Soar J, Pumphrey R, Cant A, Clarke S, Corbett A, Dawson P, et al. on behalf of Working Group of the Resuscitation Council (UK). Statement Paper. Emergency treatment of anaphylactic reactions – guidelines for healthcare providers. Resuscitation 2008;77:157-69.

12. Simons FER, Ardusso LRF, Bilo MB, El-Gamal YM, Ledford DK, Ring J, et al. World Allergy Organization guidelines for the assessment and management of anaphylaxis. J Allergy Clin Immunol 2011;127:587-93.

13. Alrasbi M, Sheikh A. Review article. Comparison of international guidelines for the emergency medical management of anaphylaxis. Allergy 2007:62:838-41.

14. Sheikh A, Hippisley-Cox J, Newton J, Fenty J. Trends in national incidence, lifetime prevalence and adrenaline prescribing for anaphylaxis in England. J R Soc Med 2008;101:139-43.

15. Lauritano EC, Novi A, Santoro MC, Casagranda I. Incidence, clinical features and management of acute allergic reactions: the experience of a single, Italian Emergency Department. European Review for Medical and pharmacological Sciences 2013;17(Suppl 1):39-44.

16. AAAI Board of Directors. The use of epinephrine in the treatment of anaphylaxis. J Allergy Clin Immunol 1994;94:666-8.

17. Xu YS, Kastner M, Harada L, Xu A, Salter J, Waserman S. Anaphylaxis-related deaths in Ontario: a retrospective review of cases from 1986 to 2011. Allergy Asthma Clin Immunol 2014;10:38.

18. Brown SGA. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol 2004;114:371-6.

19. Brown SGA, Blackman KE, Stenlake V, Heddle RJ. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004;21:149-54.

20. Panesar SS, Javad S, De Silva D, Nwaru BI, Hickstein L, Muraro A, et al. The epidemiology of anaphylaxis in Europe: a systematic review. Allergy 2013;68:1353-61.

21. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000;30:1144-50.

22. Brown SGA. Cardiovascular aspects of anaphylaxis: implications for treatment and diagnosis. Curr Opin Allergy Clin Immunol 2005;5:359-64.

23. Kounis NG. Kounis syndrome (allergic angina and allergic myocardial infarction): a natural paradigm? Int J Cardiol 2006;110:7-14.

24. Marone G, Bova M, Detoraki A, Onorati AM, Rossi FW, Spadaro G. The human heart as a shock organ in anaphylaxis. Novartis Found Symp 2004;257:133-49.

25. Lippi G, Cervellin G, Sanchis-Gomar F. Immunoglobulin E (IgE) and ischemic heart disease. Which came first, the chicken or the egg? Annals Med 2014;46:456-63.

26. Kemp SF, Lockey RF. Anaphylaxis: a review of causes and mechanisms. J Allergy Clin Immunol 2002;110:341–8.

27. Sheikh A, Shehata YA, Brown SGA, Simons FER. Adrenaline for the treatment of anaphylaxis: cochrane systematic Review. Allergy 2009:64:204-12.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 0.5(2021) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time

Conferences

Top