Up-to-date diagnosis and treatment of anaphylactic reaction

Czech version

Authors: F. Keller ¹; M. Kratochvíl ²; J. Maláska ¹
Authors‘ workplace: Klinika anesteziologie, resuscitace a intenzivní medicíny, Fakultní nemocnice Brno, Lékařská fakulta Masarykovy univerzity ¹; Klinika dětské anesteziologie a resuscitace, Fakultní nemocnice Brno, Lékařská fakulta Masarykovy univerzity ²
Published in: Anest. intenziv. Med., 33, 2022, č. 2, s. 71-78
Category: Review Article

Overview

The article summarizes up-to-date knowledge about effective diagnosis and treatment of anaphylactic reaction. It covers management of the acute anaphylactic reaction within the scope of emergency medicine, with special focus on the usage of intramuscularly injected adrenaline. Topics such as testing for allergies or the specific patophysiology of the anaphylaxis are not emphasized. The article is based on up-to-date guidelines and additional scientific evidence. Knowledge about the etiology and the risk factors is essential when diagnosing anaphylaxis. The diagnosis itself is based on the case circumstances, patients medical history and a physicians ability to assess the diverse signs of anaphylaxis. The ability to quickly diagnose, treat and immediately apply epinephrine is essential to halt the reaction in its beginning. A severe case of anaphylaxis can cause multiple serious organ dysfunctions resulting in refractory anaphylaxis and shock requiring organ support and specific medical measures. After the initial treatment, sequential procedures must be undertaken to minimalize the risk of a recurrent anaphylactic episode.

Keywords:

anaphylaxis – anaphylactic shock – epinephrine – Kounis syndrome

Sources

1. Gibbison B, Sheikh A, McShane P, Haddow C, Soar J. Anaphylaxis admissions to UK critical care units between 2005 and 2009. Anaesthesia. 2012 Aug;67(8):833-839. doi: 10.1111/j.1365-2044.2012.07159.x. Epub 2012 May 18. PMID: 22607557.

2. Reber LL, Hernandez JD, Galli SJ. The pathophysiology of anaphylaxis. J Allergy Clin Immunol. 2017 Aug;140(2):335–348. doi: 10.1016/j.jaci.2017. 06. 003. PMID: 28780941; PMCID: PMC5657389.

3. Worm M, Moneret‑Vautrin A, Scherer K, Lang R, Fernandez‑Rivas M, Cardona V, et al. First European data from the network of severe allergic reactions (NORA). Allergy. 2014 Oct;69(10):1397- 1404. doi: 10.1111/all.12475. Epub 2014 Aug 16. PMID: 24989080.

4. Simons FE, Ardusso LR, Bilò MB, El‑Gamal YM, Ledford DK, Ring J, et al.; World Allergy Organization. World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011 Feb;4(2):13-37. doi: 10.1097/WOX.0b013e318211496c. Epub 2011 Feb 23. PMID: 23268454; PMCID: PMC3500036.

5. Simons FE, Ebisawa M, Sanchez‑Borges M, Thong BY, Worm M, Tanno LK, et al. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organ J. 2015 Oct 28;8(1):32. doi: 10.1186/s40413-015-0080-1. PMID: 26525001; PMCID: PMC4625730.

6. Coop CA, Schapira RS, Freeman TM. Are ACE Inhibitors and Beta‑blockers Dangerous in Patients at Risk for Anaphylaxis? J Allergy Clin Immunol Pract. 2017 Sep‑Oct; 5(5):1207-1211. doi: 10.1016/j.jaip.2017. 04. 033. Epub 2017 May 25. PMID: 28552379.

7. Nassiri M, Babina M, Dölle S, Edenharter G, Ruëff F, Worm M. Ramipril and metoprolol intake aggravate human and murine anaphylaxis: evidence for direct mast cell priming. J Allergy Clin Immunol. 2015 Feb;135(2):491-499. doi: 10.1016/j.jaci.2014. 09. 004. Epub 2014 Oct 16. PMID: 25441633.

8. Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Bernstein D, Bernstein J, et al. Anaphylaxis-- a practice parameter update 2015. Ann Allergy Asthma Immunol. 2015 Nov;115(5):341- 384. doi: 10.1016/j.anai.2015. 07. 019. PMID: 26505932.

9. González‑Pérez A, Aponte Z, Vidaurre CF, Rodríguez LA. Anaphylaxis epidemiology in patients with and patients without asthma: a United Kingdom database review. J Allergy Clin Immunol. 2010 May;125(5):1098-1104.e1. doi: 10.1016/j.jaci.2010. 02. 009. Epub 2010 Apr 14. PMID: 20392483.

10. Valent P. Risk factors and management of severe life‑threatening anaphylaxis in patients with clonal mast cell disorders. Clin Exp Allergy. 2014 Jul;44(7):914-920. doi: 10.1111/cea.12318. PMID: 24702655; PMCID: PMC4603355.

11. Fellinger C, Hemmer W, Wöhrl S, Sesztak‑Greinecker G, Jarisch R, Wantke F. Clinical characteristics and risk profile of patients with elevated baseline serum tryptase. Allergol Immunopathol (Madr). 2014 Nov‑Dec; 42(6):544-552. doi: 10.1016/j.aller.2014. 05. 002. Epub 2014 Sep 12. PMID: 25224360.

12. Gülen T, Hägglund H, Sander B, Dahlén B, Nilsson G. The presence of mast cell clonality in patients with unexplained anaphylaxis. Clin Exp Allergy. 2014 Sep;44(9):1179-1187. doi: 10.1111/cea.12369. PMID: 25039926.

13. Ring J, Klimek L, Worm M. Adrenaline in the Acute Treatment of Anaphylaxis. Dtsch Arztebl Int. 2018 Aug 6;115(31-32):528-534. doi: 10.3238/arztebl.2018.0528. PMID: 30149833; PMCID: PMC6131363.

14. Grabenhenrich LB, Dölle S, Moneret‑Vautrin A, Köhli A, Lange L, Spindler T, et al. Anaphylaxis in children and adolescents: The European Anaphylaxis Registry. J Allergy Clin Immunol. 2016 Apr;137(4):1128-1137.e1. doi: 10.1016/j.jaci.2015. 11. 015. Epub 2016 Jan 21. PMID: 26806049.

15. Simons FE, Sampson HA. Anaphylaxis: Unique aspects of clinical diagnosis and management in infants (birth to age 2 years). J Allergy Clin Immunol. 2015 May;135(5):1125–1131. doi: 10.1016/j.jaci.2014. 09. 014. Epub 2014 Oct 30. PMID: 25441636.

16. Lieberman P, Simons FE. Anaphylaxis and cardiovascular disease: therapeutic dilemmas. Clin Exp Allergy. 2015 Aug;45(8):1288-1295. doi: 10.1111/cea.12520. Erratum in: Clin Exp Allergy. 2015 Dec;45(12):1914. PMID: 25711241.

17. Lee S, Sadosty AT, Campbell RL. Update on biphasic anaphylaxis. Curr Opin Allergy Clin Immunol. 2016 Aug;16(4):346-351. doi: 10.1097/ACI.0000000000000279. PMID: 27253484.

18. Lee S, Bellolio MF, Hess EP, Erwin P, Murad MH, Campbell RL. Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta‑analysis. J Allergy Clin Immunol Pract. 2015 May‑Jun; 3(3):408-416.e1-2. doi: 10.1016/j.jaip.2014. 12. 010. Epub 2015 Feb 11. PMID: 25680923.

19. Alqurashi W, Ellis AK. Do Corticosteroids Prevent Biphasic Anaphylaxis? J Allergy Clin Immunol Pract. 2017 Sep‑Oct; 5(5):1194-1205. doi: 10.1016/j.jaip.2017. 05. 022. PMID: 28888249.

20. Abdelghany M, Subedi R, Shah S, Kozman H. Kounis syndrome: A review article on epidemiology, diagnostic findings, management and complications of allergic acute coronary syndrome. Int J Cardiol. 2017 Apr 1;232:1-4. doi: 10.1016/j.ijcard.2017. 01. 124. Epub 2017 Jan 27. PMID: 28153536.

21. Campbell RL, Li JT, Nicklas RA, Sadosty AT; Members of the Joint Task Force; Practice Parameter Workgroup. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014 Dec;113(6):599-608. doi: 10.1016/j. anai.2014. 10. 007. PMID: 25466802.

22. Campbell RL, Hagan JB, Manivannan V, Decker WW, Kanthala AR, Bellolio MF, et al. Evaluation of national institute of allergy and infectious diseases/food allergy and anaphylaxis network criteria for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol. 2012 Mar;129(3):748-752. doi: 10.1016/j.jaci.2011. 09. 030. Epub 2011 Nov 1. PMID: 22051698.

23. Gouel‑Chéron A, Harpan A, Mertes PM, Longrois D. Management of anaphylactic shock in the operating room. Presse Med. 2016 Sep;45(9):774-783. doi: 10.1016/j.lpm.2016. 04. 002. Epub 2016 May 18. PMID: 27208918.

24. Lott C, Truhlář A, Alfonzo A, Barelli A, González‑Salvado V, Hinkelbein J, et al.; ERC Special Circumstances Writing Group Collaborators. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021 Apr;161:152-219. doi: 10.1016/j.resuscitation.2021. 02. 011. Epub 2021 Mar 24. Erratum in: Resuscitation. 2021 Oct;167:91-92. PMID: 33773826.

25. Fleming JT, Clark S, Camargo CA Jr, Rudders SA. Early treatment of food‑ induced anaphylaxis with epinephrine is associated with a lower risk of hospitalization. J Allergy Clin Immunol Pract. 2015 Jan‑Feb; 3(1):57-62. doi: 10.1016/j.jaip.2014. 07. 004. Epub 2014 Sep 8. PMID: 25577619.

26. Muraro A, Roberts G, Worm M, Bilò MB, Brockow K, Fernández Rivas M, et al.; EAACI Food Allergy and Anaphylaxis Guidelines Group. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy. 2014 Aug;69(8):1026-1045. doi: 10.1111/all.12437. Epub 2014 Jun 9. PMID: 24909803.

27. Pumphrey RS. Fatal posture in anaphylactic shock. J Allergy Clin Immunol. 2003 Aug;112(2):451-452. doi: 10.1067/mai.2003.1614. PMID: 12897756.

28. Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. 2001 Nov;108(5):871-873. doi: 10.1067/ mai.2001.119409. PMID: 11692118.

29. Campbell RL, Bellolio MF, Knutson BD, Bellamkonda VR, Fedko MG, Nestler DM, et al. Epinephrine in anaphylaxis: higher risk of cardiovascular complications and overdose after administration of intravenous bolus epinephrine compared with intramuscular epinephrine. J Allergy Clin Immunol Pract. 2015 Jan– Feb;3(1):76-80. doi: 10.1016/j. jaip.2014. 06. 007. Epub 2014 Aug 29. PMID: 25577622.

30. Xing Y, Zhang H, Sun S, Ma X, Pleasants RA, Tang H, et al. Clinical features and treatment of pediatric patients with drug‑ induced anaphylaxis: a study based on pharmacovigilance data. Eur J Pediatr. 2018 Jan;177(1):145-154. doi: 10.1007/s00431-017-3048-z. Epub 2017 Nov 22. PMID: 29168013; PMCID: PMC5748398.

31. Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez‑Mejias A, Biarent D, et al. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation. 2021 Apr;161:327–387. doi: 10.1016/j.resuscitation.2021. 02. 015. Epub 2021 Mar 24. PMID: 33773830.

32. Garvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R, et al. Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations. Br J Anaesth. 2019 Jul;123(1):e50-e64. doi: 10.1016/j. bja.2019. 04. 044. Epub 2019 May 24. PMID: 31130272.

33. Grabenhenrich LB, Dölle S, Ruëff F, Renaudin JM, Scherer K, Pföhler C, et al. Epinephrine in Severe Allergic Reactions: The European Anaphylaxis Register. J Allergy Clin Immunol Pract. 2018 Nov– Dec;6(6):1898-1906.e1. doi: 10.1016/j.jaip.2018. 02. 026. Epub 2018 Mar 30. PMID: 29606638.

34. Lin RY, Curry A, Pesola GR, Knight RJ, Lee HS, Bakalchuk L, et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med. 2000 Nov;36(5):462-468. doi: 10.1067/mem.2000.109445. PMID: 11054200.

35. Choo KJ, Simons FE, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. Evid Based Child Health. 2013 Jul;8(4):1276-1294. doi: 10.1002/ebch.1925. PMID: 23877942.

36. Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010 Sep;126(3):477-480.e1-42. doi: 10.1016/j.jaci.2010. 06. 022. Epub 2010 Aug 7. Erratum in: J Allergy Clin Immunol. 2010 Dec;126(6):1104. PMID: 20692689.

37. Harper NJN, Cook TM, Garcez T, Lucas DN, Thomas M, Kemp H, et al. Anaesthesia, surgery, and life‑threatening allergic reactions: management and outcomes in the 6th National Audit Project (NAP6). Br J Anaesth. 2018 Jul;121(1):172-188. doi: 10.1016/j.bja.2018. 04. 015. Epub 2018 May 21. PMID: 29935569.

38. Mackway‑Jones K. Best evidence topic report. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Emerg Med J. 2006 Apr;23(4):300. doi: 10.1136/emj.2006.035121. PMID: 16549579; PMCID: PMC2579508.

39. Jang DH, Nelson LS, Hoffman RS. Methylene blue for distributive shock: a potential new use of an old antidote. J Med Toxicol. 2013 Sep;9(3):242-249. doi: 10.1007/s13181-013- 0298-7. PMID: 23580172; PMCID: PMC3770994.

40. Da Silva PS, Furtado P. Methylene Blue to Treat Refractory Latex‑ Induced Anaphylactic Shock: A Case Report. A A Pract. 2018 Feb 1;10(3):57-60. doi: 10.1213/ XAA.0000000000000630. PMID: 28937421.

41. Chan‑Dominy AC, Anders M, Millar J, Horton S, Best D, Brizard C, et al. Extracorporeal membrane modality conversions. Perfusion. 2015 May;30(4):291-294. doi: 10.1177/0267659114544486. Epub 2014 Jul 28. PMID: 25070898.

42. Weiss GM, Fandrick AD, Sidebotham D. Successful rescue of an adult with refractory anaphylactic shock and abdominal compartment syndrome with venoarterial extracorporeal membrane oxygenation and bedside laparotomy. Semin Cardiothorac Vasc Anesth. 2015 Mar;19(1):66-70. doi: 10.1177/1089253214564192. Epub 2014 Dec 31. PMID: 25552268.

43. Zhang ZP, Su X, Liu CW. Cardiac arrest with anaphylactic shock: a successful resuscitation using extracorporeal membrane oxygenation. Am J Emerg Med. 2015 Jan;33(1):130. e3-4. doi: 10.1016/j.ajem.2014. 06. 034. Epub 2014 Jul 1. PMID: 25088440.

44. Kounis NG. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med. 2016 Oct 1;54(10):1545-1559. doi: 10.1515/cclm-2016-0010. PMID: 26966931.