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Original article

Vol. 153 No. 3 (2023)

Use of epinephrine in anaphylaxis: a retrospective cohort study at a Swiss university emergency department

  • Simone Ehrhard
  • Dominic Gautschi
  • Vicky Eyb
  • Stefan K. Schauber
  • Meret E. Ricklin
  • Jolanta Klukowska-Rötzler
  • Aristomenis K. Exadaktylos
  • Arthur Helbling
DOI
https://doi.org/10.57187/smw.2023.40065
Cite this as:
Swiss Med Wkly. 2023;153:40065
Published
22.03.2023

Summary

AIMS OF THE STUDY: Anaphylaxis is a medical emergency and requires prompt treatment to prevent life-threatening conditions. Epinephrine, considered as the first-line drug, is often not administered. We aimed first to analyse the use of epinephrine in patients with anaphylaxis in the emergency department of a university hospital and secondly to identify factors that influence the use of epinephrine.

METHODS: We performed a retrospective analysis of all patients admitted with moderate or severe anaphylaxis to the emergency department between 1 January 2013 and 31 December 2018. Patient characteristics and treatment information were extracted from the electronic medical database of the emergency department.

RESULTS: A total of 531 (0.2%) patients with moderate or severe anaphylaxis out of 260,485 patients admitted to the emergency department were included. Epinephrine was administered in 252 patients (47.3%). In a multivariate logistic regression, cardiovascular (Odds Ratio [OR] = 2.94, CI 1.96–4.46, p <0.001) and respiratory symptoms (OR = 3.14, CI 1.95–5.14, p<0.001) were associated with increased likelihood of epinephrine administration, in contrast to integumentary symptoms (OR = 0.98, CI 0.54–1.81, p = 0.961) and gastrointestinal symptoms (OR = 0.62, CI 0.39–1.00, p = 0.053).

CONCLUSIONS: Less than half of the patients with moderate and severe anaphylaxis received epinephrine according to guidelines. In particular, gastrointestinal symptoms seem to be misrecognised as serious symptoms of anaphylaxis. Training of the emergency medical services and emergency department medical staff and further awareness are crucial to increase the administration rate of epinephrine in anaphylaxis.

References

  1. Fischer D , Vander Leek TK , Ellis AK , Kim H . Anaphylaxis. Allergy Asthma Clin Immunol. 2018 Sep;14(S2 Suppl 2):54. https://doi.org/10.1186/s13223-018-0283-4 DOI: https://doi.org/10.1186/s13223-018-0283-4
  2. Muraro A , Werfel T , Hoffmann-Sommergruber K , Roberts G , Beyer K , Bindslev-Jensen C , et al.; EAACI Food Allergy and Anaphylaxis Guidelines Group . EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy. 2014 Aug;69(8):1008–25. https://doi.org/10.1111/all.12429 DOI: https://doi.org/10.1111/all.12429
  3. Ring J , Beyer K , Biedermann T , Bircher A , Fischer M , Fuchs T , et al. Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE). Allergo J Int. 2021;30(1):1–25. https://doi.org/10.1007/s40629-020-00158-y DOI: https://doi.org/10.1007/s40629-020-00158-y
  4. Sampson HA , Muñoz-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 Feb;117(2):391–7. https://doi.org/10.1016/j.jaci.2005.12.1303 DOI: https://doi.org/10.1016/j.jaci.2005.12.1303
  5. Simons FE , Ardusso LR , Bilò MB , Cardona V , Ebisawa M , El-Gamal YM , et al. International consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014 May;7(1):9. https://doi.org/10.1186/1939-4551-7-9 DOI: https://doi.org/10.1186/1939-4551-7-9
  6. 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;126(3):477-80.e1-42. DOI: https://doi.org/10.1016/j.jaci.2010.06.022
  7. 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):1026–45. https://doi.org/10.1111/all.12437 DOI: https://doi.org/10.1111/all.12437
  8. Alvarez-Perea A , Tanno LK , Baeza ML . How to manage anaphylaxis in primary care. Clin Transl Allergy. 2017 Dec;7(1):45. https://doi.org/10.1186/s13601-017-0182-7 DOI: https://doi.org/10.1186/s13601-017-0182-7
  9. Choi YJ , Kim J , Jung JY , Kwon H , Park JW . Underuse of Epinephrine for Pediatric Anaphylaxis Victims in the Emergency Department: A Population-based Study. Allergy Asthma Immunol Res. 2019 Jul;11(4):529–37. https://doi.org/10.4168/aair.2019.11.4.529 DOI: https://doi.org/10.4168/aair.2019.11.4.529
  10. 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. https://doi.org/10.1097/WOX.0b013e318211496c DOI: https://doi.org/10.1097/WOX.0b013e318211496c
  11. Brown JC , Simons E , Rudders SA . Epinephrine in the Management of Anaphylaxis. J Allergy Clin Immunol Pract. 2020 Apr;8(4):1186–95. https://doi.org/10.1016/j.jaip.2019.12.015 DOI: https://doi.org/10.1016/j.jaip.2019.12.015
  12. 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):341–84. https://doi.org/10.1016/j.anai.2015.07.019 DOI: https://doi.org/10.1016/j.anai.2015.07.019
  13. Anagnostou K , Turner PJ . Myths, facts and controversies in the diagnosis and management of anaphylaxis. Arch Dis Child. 2019 Jan;104(1):83–90. https://doi.org/10.1136/archdischild-2018-314867 DOI: https://doi.org/10.1136/archdischild-2018-314867
  14. Shaker MS , Wallace DV , Golden DB , Oppenheimer J , Bernstein JA , Campbell RL , et al.; Collaborators; Chief Editors; Workgroup Contributors; Joint Task Force on Practice Parameters Reviewers . Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol. 2020 Apr;145(4):1082–123. https://doi.org/10.1016/j.jaci.2020.01.017 DOI: https://doi.org/10.1016/j.jaci.2020.01.017
  15. Wood RA , Camargo CA Jr , Lieberman P , Sampson HA , Schwartz LB , Zitt M , et al. Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States. J Allergy Clin Immunol. 2014 Feb;133(2):461–7. https://doi.org/10.1016/j.jaci.2013.08.016 DOI: https://doi.org/10.1016/j.jaci.2013.08.016
  16. Prince BT , Mikhail I , Stukus DR . Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. J Asthma Allergy. 2018 Jun;11:143–51. https://doi.org/10.2147/JAA.S159400 DOI: https://doi.org/10.2147/JAA.S159400
  17. Sheikh A , Shehata YA , Brown SG , Simons FE . Adrenaline for the treatment of anaphylaxis: cochrane systematic review. Allergy. 2009 Feb;64(2):204–12. https://doi.org/10.1111/j.1398-9995.2008.01926.x DOI: https://doi.org/10.1111/j.1398-9995.2008.01926.x
  18. Ring J , Messmer K . Incidence and severity of anaphylactoid reactions to colloid volume substitutes. Lancet. 1977 Feb;1(8009):466–9. https://doi.org/10.1016/S0140-6736(77)91953-5 DOI: https://doi.org/10.1016/S0140-6736(77)91953-5
  19. Rutschmann OT , Hugli OW , Marti C , Grosgurin O , Geissbuhler A , Kossovsky M , et al. Reliability of the revised Swiss Emergency Triage Scale: a computer simulation study. Eur J Emerg Med. 2018 Aug;25(4):264–9. https://doi.org/10.1097/MEJ.0000000000000449 DOI: https://doi.org/10.1097/MEJ.0000000000000449
  20. Dudley LS , Mansour MI , Merlin MA . Epinephrine for anaphylaxis: underutilized and unavailable. West J Emerg Med. 2015 May;16(3):385–7. https://doi.org/10.5811/westjem.2015.3.25337 DOI: https://doi.org/10.5811/westjem.2015.3.25337
  21. De Vera MJ , Tagaro IC . Anaphylaxis diagnosis and management in the Emergency Department of a tertiary hospital in the Philippines. Asia Pac Allergy. 2020 Jan;10(1):e1. https://doi.org/10.5415/apallergy.2020.10.e1 DOI: https://doi.org/10.5415/apallergy.2020.10.e1
  22. Lippner E , Dinakar C. Increasing Emergency Department Visits for Anaphylaxis, 2005-2014. Pediatrics. 2017;140(Supplement 3):S188.1-S. DOI: https://doi.org/10.1542/peds.2017-2475CC
  23. Turner PJ , Campbell DE , Motosue MS , Campbell RL . Global Trends in Anaphylaxis Epidemiology and Clinical Implications. J Allergy Clin Immunol Pract. 2020 Apr;8(4):1169–76. https://doi.org/10.1016/j.jaip.2019.11.027 DOI: https://doi.org/10.1016/j.jaip.2019.11.027
  24. Simons KJ , Simons FE . Epinephrine and its use in anaphylaxis: current issues. Curr Opin Allergy Clin Immunol. 2010 Aug;10(4):354–61. https://doi.org/10.1097/ACI.0b013e32833bc670 DOI: https://doi.org/10.1097/ACI.0b013e32833bc670
  25. Ruiz Oropeza A , Lassen A , Halken S , Bindslev-Jensen C , Mortz CG . Anaphylaxis in an emergency care setting: a one year prospective study in children and adults. Scand J Trauma Resusc Emerg Med. 2017 Nov;25(1):111. https://doi.org/10.1186/s13049-017-0402-0 DOI: https://doi.org/10.1186/s13049-017-0402-0
  26. Fleischer DM , Perry TT , Atkins D , Wood RA , Burks AW , Jones SM , et al. Allergic reactions to foods in preschool-aged children in a prospective observational food allergy study. Pediatrics. 2012 Jul;130(1):e25–32. https://doi.org/10.1542/peds.2011-1762 DOI: https://doi.org/10.1542/peds.2011-1762
  27. Robinson M , Greenhawt M , Stukus DR . Factors associated with epinephrine administration for anaphylaxis in children before arrival to the emergency department. Ann Allergy Asthma Immunol. 2017 Aug;119(2):164–9. https://doi.org/10.1016/j.anai.2017.06.001 DOI: https://doi.org/10.1016/j.anai.2017.06.001
  28. DeSantiago-Cardenas L , Rivkina V , Whyte SA , Harvey-Gintoft BC , Bunning BJ , Gupta RS . Emergency epinephrine use for food allergy reactions in Chicago Public Schools. Am J Prev Med. 2015 Feb;48(2):170–3. https://doi.org/10.1016/j.amepre.2014.09.005 DOI: https://doi.org/10.1016/j.amepre.2014.09.005
  29. Curtis C , Stukus D , Scherzer R . Epinephrine preparedness in pediatric patients with food allergy: an ideal time for change. Ann Allergy Asthma Immunol. 2014 Jun;112(6):560–2. https://doi.org/10.1016/j.anai.2014.04.009 DOI: https://doi.org/10.1016/j.anai.2014.04.009
  30. Duvauchelle T , Robert P , Donazzolo Y , Loyau S , Orlandini B , Lehert P , et al. Bioavailability and Cardiovascular Effects of Adrenaline Administered by Anapen Autoinjector in Healthy Volunteers. J Allergy Clin Immunol Pract. 2018;6(4):1257–63. https://doi.org/10.1016/j.jaip.2017.09.021 DOI: https://doi.org/10.1016/j.jaip.2017.09.021
  31. 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;3(3):408-16.e1-2. DOI: https://doi.org/10.1016/j.jaip.2014.12.010
  32. Simons FE , Clark S , Camargo CA Jr . Anaphylaxis in the community: learning from the survivors. J Allergy Clin Immunol. 2009 Aug;124(2):301–6. https://doi.org/10.1016/j.jaci.2009.03.050 DOI: https://doi.org/10.1016/j.jaci.2009.03.050
  33. Kastner M , Harada L , Waserman S . Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature. Allergy. 2010 Apr;65(4):435–44. https://doi.org/10.1111/j.1398-9995.2009.02294.x DOI: https://doi.org/10.1111/j.1398-9995.2009.02294.x
  34. Ko BS , Kim JY , Seo DW , Kim WY , Lee JH , Sheikh A , et al. Should adrenaline be used in patients with hemodynamically stable anaphylaxis? Incident case control study nested within a retrospective cohort study. Sci Rep. 2016 Feb;6(1):20168. https://doi.org/10.1038/srep20168 DOI: https://doi.org/10.1038/srep20168
  35. Ring J , Klimek L , Worm M . Adrenaline in the Acute Treatment of Anaphylaxis. Dtsch Arztebl Int. 2018 Aug;115(31-32):528–34. https://doi.org/10.3238/arztebl.2018.0528 DOI: https://doi.org/10.3238/arztebl.2018.0528
  36. Kawano T , Scheuermeyer FX , Stenstrom R , Rowe BH , Grafstein E , Grunau B . Epinephrine use in older patients with anaphylaxis: clinical outcomes and cardiovascular complications. Resuscitation. 2017 Mar;112:53–8. https://doi.org/10.1016/j.resuscitation.2016.12.020 DOI: https://doi.org/10.1016/j.resuscitation.2016.12.020
  37. Tejedor-Alonso MA , Pérez-Codesido S , Nieto-Nieto A , Gonzalez-Moreno A , Rosado Ingelmo A , Laiseca García J , et al. Recurrence of anaphylaxis: A systematic review of observational studies. Allergy. 2021. DOI: https://doi.org/10.1111/all.15156
  38. 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):1397–404. https://doi.org/10.1111/all.12475 DOI: https://doi.org/10.1111/all.12475
  39. Kemp SF , Lockey RF , Simons FE ; World Allergy Organization ad hoc Committee on Epinephrine in Anaphylaxis . Epinephrine: the drug of choice for anaphylaxis-a statement of the world allergy organization. World Allergy Organ J. 2008 Jul;1(7 Suppl):S18–26. https://doi.org/10.1097/WOX.0b013e31817c9338 DOI: https://doi.org/10.1186/1939-4551-1-S2-S18
  40. Waserman S , Chad Z , Francoeur MJ , Small P , Stark D , Vander Leek TK , et al. Management of anaphylaxis in primary care: canadian expert consensus recommendations. Allergy. 2010 Sep;65(9):1082–92. https://doi.org/10.1111/j.1398-9995.2010.02418.x DOI: https://doi.org/10.1111/j.1398-9995.2010.02418.x
  41. Muraro A , Halken S , Arshad SH , Beyer K , Dubois AE , Du Toit G , et al.; EAACI Food Allergy and Anaphylaxis Guidelines Group . EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy. Allergy. 2014 May;69(5):590–601. https://doi.org/10.1111/all.12398 DOI: https://doi.org/10.1111/all.12398

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