Administration Of Epinephrine Research Articles

Effect of no-flow period on the vasopressor effect of initial epinephrine administration in cardiac arrest

ObjectivesWhether a longer no-flow (NF) interval affects the magnitude of response to epinephrine in the resuscitation has not been well studied. Therefore, this study aimed to evaluate the effect of NF interval on the vasopressor effect of initial epinephrine administration in a porcine model. MethodsWe enrolled 20 pigs from two randomized porcine experimental studies using a ventricular fibrillation (VF) cardiac arrest model. The first experiment subjects were resuscitated after 4 min of NF (Short NF group), followed by three cycles (6 min) of chest compression using a mechanical cardiopulmonary resuscitation device before epinephrine administration. Second experiment subjects received 6 min of NF (Long NF group), two cycles (4 min) of chest compressions, and administration of epinephrine. Defibrillation for VF was delivered 8 and 10 min after VF induction in the Short NF and Long NF groups, respectively. The mean arterial pressure (MAP) and cerebral perfusion pressure (CePP) in the 2-min resuscitation period after epinephrine administration were compared between the study groups using the Wilcoxon rank-sum test. The mean differences in the parameters between phases were also compared. ResultsSeven pigs in the Short NF group and 13 pigs in the Long NF group were included in the analysis. All 2-min resuscitation phases from 6 to 16 min after VF induction were compared between the study groups. The Short NF group showed higher MAP and CePP in all phases (p < 0.01). Change of mean MAP after the epinephrine administration was significantly different between the study groups: mean difference (95% confidence interval) of 16.6 (15.8–17.4) mmHg in the Short NF group and 4.2 (3.9–4.5) mmHg in the Long NF group. ConclusionIn the porcine VF cardiac arrest model, 6 min of NF before resuscitation may affect the vasopressor effect of the initial epinephrine administered compared to 4 min of NF. A short NF may play a role in maximizing the effect of epinephrine in advanced cardiovascular life support.

Factors Associated With Epinephrine Use in the Treatment of Anaphylaxis in Infants and Toddlers

Undertreatment of anaphylaxis with epinephrine continues to be an unmet need and is a particular challenge among infants and toddlers. To address this gap by identifying barriers and solutions to appropriate and timely administration of epinephrine. We conducted a national online survey among primary caregivers of children who experienced a severe food-induced allergic reaction when younger than 36 months. Outcomes of interest included epinephrine use in community and health care settings to treat probable anaphylaxis. Of 264 probable anaphylaxis cases, 39% of infants (aged <12 months) and 61% of toddlers (aged 12-35 months) received epinephrine at any time during the child's most severe allergic reaction (P= .001). A previous diagnosis of a food allergy was reported in 62% of cases where epinephrine was used compared with 26% of cases where epinephrine was not used (P< .001). In children with a previous diagnosis of a food allergy, epinephrine was used in 89% of those who were prescribed an anaphylaxis action plan compared with 50% of those without a plan (P= .001). The adjusted odds ratio for the association between having an anaphylaxis action plan and epinephrine use in cases of probable anaphylaxis was 5.39 (95% confidence interval, 2.18-13.30). Epinephrine use at any time (including in health care settings) during probable anaphylaxis is more likely in infants and toddlers with a previously diagnosed food allergy than those without diagnosis. The provision of an anaphylaxis action plan is also associated with increased epinephrine use during probable anaphylaxis in this population.

Management of anaphylaxis

Health visitors should be aware of the signs and symptoms of anaphylaxis, in addition to the administration of adrenaline, as the quicker treatment is provided, the greater the chance of recovery

Ironing out the Wrinkles: Low Molecular Weight Iron Dextran and Premedications

Intravenous (IV) iron infusion increases hemoglobin levels and reduces the need for transfusions compared to oral iron in patients with iron deficiency. Low molecular weight iron dextran (LMW ID) has a boxed warning for anaphylactic-type infusion reactions and premedication is commonly given. However, a recent multi-institution cohort study showed similar rates of infusion-related adverse events (AEs) with iron sucrose (4.3%) and iron dextran (3.8%), and a 23-fold higher incidence of AEs among those who received premedication compared with those who did not (38.6% vs 1.7%). There is currently a national shortage of iron dextran. A study during a previous iron dextran shortage in 2016 showed that the increased use of newer IV iron formulations persisted even once the shortage ended. This may in part be due to the concern for infusion reactions, but the use of these formulations comes at a significant cost. An analysis of the US FDA database showed that, based on differences in the average price of iron sucrose and LMW ID, the cost to prevent one life-threatening AE related to the use of LMW ID was estimated to be 5.0-7.8 million dollars. The cost to prevent one LMW ID-related death was estimated to be 33 million dollars. To further evaluate the incidence of infusion reactions and the use of premedication at the University of Kansas Medical Center, we performed a retrospective analysis of all patients who received their first ever infusion of iron dextran between 1/1/2021-12/31/2022. Infusion reactions were characterized as severe if hypoxia (O2&amp;lt;90%), hypotension (&amp;lt;100/80) or hospital admission occurred. Ninety-six patients were identified. 17 (17.7%) were males and 79 (82.3%) were females. There were 49 (51%) Caucasian, 26 (27.1%) African Americans, 12 (12.5%) Hispanic, and 9 (9.4%) others. 8 patients had infusion reaction (8.3%; 95% CI 4.0-15.1%) as determined by review of nursing documentation. Serious infusion reactions with LMW ID were rare (n=2, 2.1%), and neither patient required epinephrine administration nor hospitalization. Patients with history of allergies (n=61, 63.5%) had a higher incidence of AEs compared to those who did not (13.1% [95% CI, 6.4-23.2%] vs 0.0%, P = 0.022). This was even higher in 27 (28.1%) patients with 3 or more allergies (18.5% [95% CI, 7.4-35.9%] vs 0.0%, P = 0.019). In 71 (80.2%) patients who received premedication, there was a lower incidence of AEs compared to those who did not (3.9% vs 26.3%; χ2 = 10.02; P =0.007). The incidence of AEs was compared with individual premedication, and lower incidences were seen in 64 (66.7%) patients with diphenhydramine (3.1% vs 18.8%, χ2 = 6.82; P =0.015), 50 (52.1%) with methylprednisolone (2.0% vs 15.2%, χ2 = 5.48; P =0.022), and 46 (47.9%) with acetaminophen (0.0% vs 16%, χ2 = 8.03; P =0.004). Notably, a variety of premedication combinations and doses were used, indicating a lack of standardization even within a single institution. No patient who received acetaminophen experienced an infusion reaction. By contrast, there was no significant difference in patients receiving famotidine, suggesting that while acetaminophen may be a useful premedication, famotidine may not be beneficial. Further, our data strongly suggests that patients without a history of drug allergies do not require premedication. Our retrospective study demonstrates significant benefit to receiving premedication, which is divergent when compared to previous studies. This may be due to several reasons: the previously mentioned multi-center study included multiple formulations of IV iron, had a much lower rate of premedication (6% vs. 80%), and used a different definition of infusion reaction. In the multi-center cohort study, administration of medications post-iron infusion was used as a surrogate marker of reaction, while in our study it was based on review of nursing documentation. Both our study and the prior multi-center study noted an increased incidence of infusion reactions in patients with a history of allergies, and both demonstrated the rarity of serious reactions. Based on these results and the prior studies indicating the increased cost of other IV iron formulations, consideration of reinstitution of LMW ID with de-escalation of premedication in those without history of drug allergies should be considered once the current drug shortage resolves.

Quality improvement developments following pediatric resuscitation and veno-arterial extracorporeal membrane oxygenation support due to a massive intentional antidepressant overdose

Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation (ECPR) is the act of placing a patient on bypass at the bedside while simultaneously carrying out life-sustaining interventions such as chest compressions or epinephrine administration. This involves a team of physicians, nurses, respiratory therapists, pharmacists, extracorporeal membrane oxygenation (ECMO) trained staff, and other health professionals who must focus on cardiopulmonary resuscitation (CPR), cannulation, and initiating ECMO flow at the same time. ECPR may be considered when traditional CPR does not achieve return of spontaneous circulation (ROSC) in a patient. Limitations when thinking about using ECPR for a patient include location, timing from arrest to CPR initiation, as well as CPR initiation to successfully on bypass, trained staff available to begin the cannulation process, and pauses in compressions during surgery. We analyzed a pediatric patient who required ECPR after an intentional drug overdose. Gaps identified in this case prompted us to assess our ECPR protocol. Through the development and use of multidisciplinary ECPR simulations, our team discovered areas of quality improvement and put those findings into practice.

Association of prehospital advanced airway and epinephrine with survival in patients with out-of-hospital cardiac arrest

Survival benefits of prehospital advanced airway and epinephrine in out-of-hospital cardiac arrest (OHCA) patients are controversial, but few studies evaluated this together. This study evaluated association of prehospital advanced airway and epinephrine with survival outcomes in OHCA patients. This was observational study using a prospective multicentre KoCARC registry. Adult OHCA patients between October 2015 and December 2021 were included. The variables of interest were prehospital managements, which was classified into basic life support (BLS)-only, BLS + advanced airway, and BLS + advanced airway + epinephrine. In total, 8217 patients were included in analysis. Survival to discharge and good neurological outcomes were lowest in the BLS + advanced airway + epinephrine group (22.1% in BLS-only vs 13.2% in BLS + advanced airway vs 7.5% in BLS + advanced airway + epinephrine, P < 0.001 and 17.1% in BLS-only vs 9.2% in BLS + advanced airway vs 4.3% in BLS + advanced airway + epinephrine, P < 0.001, respectively). BLS + advanced airway + epinephrine group was less likely to survive to discharge and have good neurological outcomes (aOR 0.39, 95% CI 0.28–0.55, P < 0.001 and aOR 0.33, 95% CI 0.21–0.51, P < 0.001, respectively) than BLS-only group after adjusting for potential confounders. In prehospital settings with intermediate EMS providers and prehospital advanced airway insertion is performed followed by epinephrine administration, prehospital management with BLS + advanced airway + epinephrine in OHCA patients was associated with lower survival to discharge rate compared to BLS-only.

Changes in vital signs during adrenaline administration for hemostasis in intracordal injection: an observational study with a hypothetical design of endotracheal adrenaline administration in cardiopulmonary arrest

BackgroundThe background is that intravenous adrenaline administration is recommended for advanced cardiovascular life support in adults and endotracheal administration is given low priority. The reason is that the optimal dose of adrenaline in endotracheal administration is unknown, and it is ethically difficult to design studies of endotracheal adrenaline administration with non-cardiopulmonary arrest. We otolaryngologists think so because we administered adrenaline to the vocal folds for hemostasis after intracordal injection under local anesthesia, but have had few cases of vital changes. We hypothesized that examining vital signs before and after adrenaline administration for hemostasis would help determine the optimal dose of endotracheal adrenaline.MethodsWe retrospectively examined the medical records of 79 patients who visited our hospital from January 2018 to December 2020 and received adrenaline in the vocal folds and trachea for hemostasis by intracordal injection under local anesthesia to investigate changes in heart rate and systolic blood pressure before and after the injection.ResultsThe mean heart rates before and after injection were 83.96 ± 18.51 (standard deviation) beats per minute (bpm) and 81.50 ± 15.38 (standard deviation) bpm, respectively. The mean systolic blood pressure before and after the injection were 138.13 ± 25.33 (standard deviation) mmHg and 135.72 ± 22.19 (standard deviation) mmHg, respectively. Heart rate and systolic blood pressure had P-values of 0.136, and 0.450, respectively, indicating no significant differences.ConclusionsAlthough this study was an observational, changes in vital signs were investigated assuming endotracheal adrenaline administration. The current recommended dose of adrenaline in endotracheal administration with cardiopulmonary arrest may not be effective. In some cases of cardiopulmonary arrest, intravenous and intraosseous routes of adrenaline administration may be difficult and the opportunity for resuscitation may be missed. Therefore, it is desirable to have many options for adrenaline administration. Therefore, if the optimal dose and efficacy of endotracheal adrenaline administration can be clarified, early adrenaline administration will be possible, which will improve return of spontaneous circulation (ROSC) and survival discharge rates.

EFFICACY AND SAFETY OF LOCAL INTRACORONARY ADRENALINE IN THE TREATMENT OF NO RE-FLOW PHENOMENON

No flow is defined as the lack of myocardial perfusion despite opening up the epicardial coronary vessels in percutaneous coronary intervention (PCI). The study aims to find the efficacy and safety of local intracoronary adrenaline in treating the no-reflow phenomenon. This prospective observational study was conducted at the Peshawar Institute of Cardiology from January 2021 to January 2022. Data was collected from 86 patients. Data was collected through clinical assessments, angiographic evaluations, and patient records. Relevant baseline characteristics, procedural details, and outcomes were systematically documented for each participant. The average age of the participants was 62 years, with a gender distribution of 60% male and 40% female. Among the 86 patients, 42% exhibited an angiographically confirmed no-reflow phenomenon during PCI. No-reflow severity varied, with 18% experiencing mild, 15% moderate, and 9% severe no-reflow. Local intracoronary adrenaline was administered as part of the treatment strategy for the no-reflow phenomenon in the eligible patients. The standardized dose of adrenaline used was 100 μg, administered via the intracoronary route during the PCI procedure. It is concluded that local intracoronary adrenaline administration appears to be a potentially effective and safe strategy for managing the no-reflow phenomenon during PCI procedures.

Evaluation of pediatricians' awareness about anaphylaxis.

Anaphylaxis is a severe hypersensitivity reaction with a rapid onset and is potentially life-threatening if not treated promptly. This study aimed to determine the level of knowledge of pediatricians in Turkey in recognizing and treating the clinical symptoms of anaphylaxis, compare the previous studies conducted in Turkey chronologically, and show the current trends on awareness of anaphylaxis in developed and developing countries in the world. Pediatric residents and specialists from all over Turkey were included in the study. A questionnaire was prepared by compiling the current literature. Questions were sent to pediatricians via online applications. Statistical tests were used to analyze the data. A total of 524 pediatricians participated in the study. All participants accepted that anaphylaxis was a life-threatening condition. Almost all suggested epinephrine as the primary drug used in anaphylaxis. The proportion of pediatricians who knew the appropriate dose, route of administration, and place of administration of epinephrine was 82.8%, 88.9%, and 89.7%, respectively. The rate of pediatricians who recognized the clinical features of anaphylaxis was over 90%. The proportion of pediatricians who knew the epinephrine auto-injector and dose was 74.4% and 53.1%, respectively. Pediatricians with less than 10 years of experience and those working in public hospitals had better knowledge about atypical symptoms of anaphylaxis. Although there are still inadequacies in identifying atypical symptoms and treating anaphylaxis, our study revealed that the level of awareness of anaphylaxis had shown an increasing trend in Turkey over time. On the other hand, the knowledge on diagnosing and treating anaphylaxis still needs to be improved, especially for physicians working in rural areas of developing countries.

TCT-554 Impact of Epinephrine Administration Route on CPR Outcomes in STEMI Patients

TCT-554 Impact of Epinephrine Administration Route on CPR Outcomes in STEMI Patients

Prehospital predicting factors using a decision tree model for patients with witnessed out-of-hospital cardiac arrest and an initial shockable rhythm

The effect of prehospital factors on favorable neurological outcomes remains unclear in patients with witnessed out-of-hospital cardiac arrest (OHCA) and a shockable rhythm. We developed a decision tree model for these patients by using prehospital factors. Using a nationwide OHCA registry database between 2005 and 2020, we retrospectively analyzed a cohort of 1,930,273 patients, of whom 86,495 with witnessed OHCA and an initial shockable rhythm were included. The primary endpoint was defined as favorable neurological survival (cerebral performance category score of 1 or 2 at 1 month). A decision tree model was developed from randomly selected 77,845 patients (development cohort) and validated in 8650 patients (validation cohort). In the development cohort, the presence of prehospital return of spontaneous circulation was the best predictor of favorable neurological survival, followed by the absence of adrenaline administration and age. The patients were categorized into 9 groups with probabilities of favorable neurological survival ranging from 5.7 to 70.8% (areas under the receiver operating characteristic curve of 0.851 and 0.844 in the development and validation cohorts, respectively). Our model is potentially helpful in stratifying the probability of favorable neurological survival in patients with witnessed OHCA and an initial shockable rhythm.

Temporal trends in out-of-hospital cardiac arrest with an initial non-shockable rhythm in Singapore

AimOut-of-hospital cardiac arrest (OHCA) with an initial non-shockable rhythm is the predominant form of OHCA in adults. We evaluated its 10-year trends in epidemiology and management in Singapore. MethodsUsing the national OHCA registry we studied the trends of 20,844 Emergency Medical Services-attended adult OHCA from April 2010 to December 2019. Survival to hospital discharge was the primary outcome. Trends and outcomes were analyzed using linear and logistic regression, respectively. ResultsIncidence rates of adult OHCAs increased during the study period, driven by non-shockable OHCA. Compared to shockable OHCA, non-shockable OHCAs were significantly older, had more co-morbidities, unwitnessed and residential arrests, longer no-flow time, and received less bystander cardiopulmonary resuscitation (CPR) and in-hospital interventions (p < 0.001). Amongst non-shockable OHCA, age, co-morbidities, residential arrests, no-flow time, time to patient, bystander CPR and epinephrine administration increased during the study period, while presumed cardiac etiology decreased (p < 0.05). Unlike shockable OHCA, survival for non-shockable OHCA did not improve (p < 0.001 for trend difference). The likelihood of survival for non-shockable OHCA significantly increased with witnessed arrest (adjusted odds ratio (aOR) 2.02) and bystander CPR (aOR 3.25), but decreased with presumed cardiac etiology (aOR 0.65), epinephrine administration (aOR 0.66), time to patient (aOR 0.93) and age (aOR 0.98). Significant two-way interactions were observed for no-flow time and residential arrest with bystander CPR (aOR 0.96 and 0.40 respectively). ConclusionThe incidence of non-shockable OHCA increased between 2010 and 2019. Despite increased interventions, survival did not improve for non-shockable OHCA, in contrast to the improved survival for shockable OHCA.

Managing anaphylaxis: Epinephrine, antihistamines, and corticosteroids: More than 10 years of Cross-Canada Anaphylaxis REgistry data

BackgroundEpinephrine is the first-line treatment for anaphylaxis but is often replaced with antihistamines or corticosteroids. Delayed epinephrine administration is a risk factor for fatal anaphylaxis. Convincing data on the role of antihistamines and corticosteroids in anaphylaxis management are sparse. ObjectiveTo establish the impact of prehospital treatment with epinephrine, antihistamines, and/or corticosteroids on anaphylaxis management. MethodsPatients presenting with anaphylaxis were recruited prospectively and retrospectively in 10 Canadian and 1 Israeli emergency departments (EDs) between April 2011 and August 2022, as part of the Cross-Canada Anaphylaxis REgistry. Data on anaphylaxis cases were collected using a standardized form.Primary outcomes were uncontrolled reactions (>2 doses of epinephrine in ED), no prehospital epinephrine use, use of intravenous fluids in ED, and hospital admission. Multivariate regression was used to identify factors associated with primary outcomes. ResultsAmong 5364 reactions recorded, median age was 8.8 years (IQR, 3.78-16.9); 54.9% of the patients were males, and 52.5% had a known food allergy. In the prehospital setting, 37.9% received epinephrine; 44.3% received antihistamines, and 3.15% received corticosteroids. Uncontrolled reactions happened in 250 reactions.Patients treated with prehospital epinephrine were less likely to have uncontrolled reactions (adjusted odds ratio [aOR], 0.955 [95% CI, 0.943-0.967]), receive intravenous fluids in ED (aOR, 0.976 [95% CI, 0.959-0.992]), and to be admitted after the reaction (aOR, 0.964 [95% CI, 0.949-0.980]). Patients treated with prehospital antihistamines were less likely to have uncontrolled reactions (aOR, 0.978 [95% CI, 0.967-0.989]) and to be admitted after the reaction (aOR, 0.963 [95% CI, 0.949-0.977]). Patients who received prehospital corticosteroids were more likely to require intravenous fluids in ED (aOR, 1.059 [95% CI, 1.013-1.107]) and be admitted (aOR, 1.232 [95% CI, 1.181-1.286]). ConclusionOur findings in this predominantly pediatric population support the early use of epinephrine and suggest a beneficial effect of antihistamines. Corticosteroid use in anaphylaxis should be revisited.

Prehospital Administration of Norepinephrine and Epinephrine for Shock after Resuscitation from Cardiac Arrest

Introduction Shock after resuscitation from out-of-hospital cardiac arrest (OHCA) is often treated with vasopressors. We examined whether infusion of epinephrine versus norepinephrine was associated with prehospital rearrest and neurologically favorable survival among OHCA patients. Methods This retrospective study included OHCA cases in Seattle, Washington from 2014-2021 who had return of spontaneous circulation (ROSC) followed by vasopressor infusion. Our primary exposure was infusion of epinephrine or norepinephrine. Our primary outcome was prehospital rearrest. Secondary outcomes included survival and neurologically favorable outcome (Cerebral Performance Category score of 1 or 2). We used multivariable logistic regression to test associations between exposures and outcomes adjusting for key covariates. Results Of 451 OHCA patients with ROSC followed by vasopressor infusion, 253 (56%) received norepinephrine and 198 (44%) received epinephrine infusions. Those who received epinephrine were older (median 66 [interquartile ranges {IQR} 53-79] vs 63 [IQR 47-75] years), but otherwise had similar baseline characteristics. Patients who received epinephrine were twice as likely to rearrest (55% vs 25%). After adjustment, the difference in rearrest rates between epinephrine and norepinephrine persisted (OR 3.28, 95%CI 2.25-5.08), and the odds of pulses at hospital arrival were lower in the epinephrine group (OR 0.52 95%CI 0.32-0.83). After adjustment, there was no difference in neurologically favorable survival, survival to hospital admission, or survival to discharge. Conclusion Patients who received epinephrine infusions after ROSC suffered prehospital rearrest more frequently than those who received norepinephrine. Survival and neurological status at hospital discharge were similar. Future trials should examine the optimal approach to hemodynamic management for post-OHCA shock.

Effect of first epinephrine administration time on cerebral perfusion pressure and cortical cerebral blood flow in a porcine cardiac arrest model

ObjectiveThe optimal time for epinephrine administration and its effects on cerebral blood flow (CBF) and microcirculation remain controversial. This study aimed to assess the effect of the first administration of epinephrine on cerebral perfusion pressure (CePP) and cortical CBF in porcine cardiac arrest model. MethodsAfter 4 min of untreated ventricular fibrillation, eight of 24 swine were randomly assigned to the early, intermediate, and late groups. In each group, epinephrine was administered intravenously at 5, 10, and 15 min after cardiac arrest induction. CePP was calculated as the difference between the mean arterial pressure and intracranial pressure. Cortical CBF was measured using a laser Doppler flow probe. The outcomes were CePP and cortical CBF measured continuously during cardiopulmonary resuscitation (CPR). Mean CePP and cortical CBF were compared using analysis of variance and a linear mixed model. ResultsThe mean CePP was significantly different between the groups at 6–11 min after cardiac arrest induction. The mean CePP in the early group was significantly higher than that in the intermediate group at 8–10 min and that in the late group at 6–9 min and 10–11 min. The mean cortical CBF was significantly different between the groups at 9–11 min. The mean cortical CBF was significantly higher in the early group than in the intermediate and late group at 9–10 min. ConclusionEarly administration of epinephrine was associated with improved CePP and cortical CBF compared to intermediate or late administration during the early period of CPR.

The Effectiveness of Obstetric Emergency Interventions in Enhancing Mother and Fetal Well-Being: A Systematic

An obstetric emergency is a condition that can threaten the life of a pregnant woman and the fetus, which occurs during pregnancy, childbirth and the puerperium. This review aimed to analyze the effectiveness of emergency obstetric interventions based on previous studies. The study was a systematic review carried out in seven stages through three databases from Ebsco, Pubmed and Proquest. The keywords used were (pregnant women) AND (emergency intervention) AND (nursing OR nurse) NOT (systematic review). The inclusion criteria in this study were: full-text, peer review, English, articles for the last five years, subject: nursing, nurses, emergency medical care, nursing care, emergency services, and document type: articles. Based on the search database, 10,496 papers were obtained, 733 documents that matched the inclusion criteria and seven papers that fit the theme were obtained. The result that based on the initial stage of the literature search, four interventions were adequate, including ACLS training, multidisciplinary management, making coloured ribbons for premature pregnancy detection, and maternal near-miss detection tools. Interventions with less effective based on statistical test results were supportive care, home visits with IPV (intimate partner violence) interventions, and administration of CPR, defibrillation, ETT insertion, and administration of epinephrine. Nurses still carry out a few emergency developmental interventions. It is necessary to develop engagement interventions related to maternal emergencies to improve the welfare of mothers and babies. Further study is needed to strengthen the evidence base of innovative interventions for specific obstetric emergencies.

Nebulised adrenaline in the post-operative management of brachycephalic obstructive airway syndrome in dogs: short-term outcomes in 90 cases (2014–2020)

ABSTRACT Case histories Medical records from a single UK-based referral hospital were retrospectively reviewed to identify brachycephalic dogs who had undergone corrective airway surgery and were nebulised with adrenaline in the post-operative period. Ninety dogs were identified between August 2014 and March 2020. Clinical findings Agitation following nebulisation with adrenaline was uncommon, with 86/90 (96%) dogs remaining calm, and overall outcome was reported as satisfactory in 68 of 73 (89%) dogs for which this information was available. Median respiratory rate at T0 (prior to first nebulisation) and T60 (1 hour following nebulisation) were both 20 breaths/minute with a median difference of 0 (95% CI = 0–0) breaths/minute (p = 0.657). Median heart rate at T0 and T60 were both 80 beats/minute with a median difference of 3 (95% CI = −10 to 7) beats/minute (p = 0.948). Two dogs experienced tachycardia, but this was not associated with the timing of administration of adrenaline. Complications reported in the 24 hours following surgery included regurgitation (n = 36), increased respiratory noise and effort (n = 10), aspiration pneumonia (n = 4), and inappetence (n = 3). A temporary tracheostomy tube was placed in 13 (14.4%) dogs. Clinical relevance Nebulisation with adrenaline is feasible, results in minimal increases in respiratory rate and heart rate and is associated with agitation in only a small number of dogs.

Anaphylaxis to oral misoprostol in a term pregnant patient who is non-allergic to vaginal misoprostol-a case report

Misoprostol (PGE1) is a drug that is very commonly used in obstetrics for labour induction. Apart from its side effect of causing congenital malformations in offspring of users who have unsuccessfully used it as an abortifacient, it is considered a safe drug with few side effects. We here report a severe hypersensitivity reaction to misoprostol in a 33-year-old term pregnant patient who is non-allergic to vaginal misoprostol. The patient developed anaphylactic features like swelling of lips, low voice due to laryngeal oedema, and bradycardia. Prompt administration of adrenaline and emergent caesarean section allowed for the safe delivery of the neonate. When inducing labour, quick identification and treatment of anaphylaxis and hypersensitivity reactions are necessary to prevent maternal and neonatal morbidity and mortality.

The etiology, risk factors, and clinical features of anaphylaxis: The single-center retrospective cohort study of the tertiary university hospital

Background/Aim: Anaphylaxis presents in multiple ways, making its diagnosis challenging. Delayed diagnosis can lead to a postponement in administering crucial adrenaline treatment. The prevalence of anaphylaxis varies by geographical region and gender. However, there has been no comprehensive regional analysis of anaphylaxis data within our country. Despite an increasing incidence, our understanding of anaphylaxis etiology, risk factors, and clinical features remains limited, particularly within our nation. This study aims to assess the frequency, etiology, risk factors, and clinical findings of anaphylaxis among patients seen at the allergy clinic of a tertiary university hospital. Additionally, it seeks to compare regional data with existing literature. Methods: This retrospective cohort study reviewed the medical records of 8,295 patients who visited the allergy outpatient clinic at Sivas Cumhuriyet University Hospital between July 2, 2018, and December 10, 2019. The hospital’s data system retrospectively analyzed records using the ICD code T78.2 (anaphylaxis). Only cases where patients were prescribed an adrenaline auto-injector were included. The study evaluated anaphylaxis frequency, etiologies, demographics, and clinical features. Results: The study identified 77 patients (n=77) with a mean age of 40.29 (3.77) years, consisting of 47 females and 30 males. The frequency of anaphylaxis among allergy outpatient admissions was less than 1% (0.009%). Single-type atopic diseases included venom allergy (23%), drug allergy (14%), inhalant allergens (n=6), food allergens (n=4), and skin allergic diseases (n=3). Multiple allergic diseases were present in 40% (n=31) of cases. Prick tests were performed on 56 (72%) patients, with 25 (44%) yielding negative results. Among positive prick test cases, venom was the main cause of anaphylaxis (82%), while drug allergy was more prevalent (68.2%) among negative test results (P=0.016). Inhalant allergen sensitivity and allergen polisensitivity did not significantly influence the anaphylaxis cause (P&lt;0.001). Causes of anaphylaxis included drug allergy (47%), venom allergy (31%), food allergens (16%), food-dependent exercise-induced reactions (n=2), idiopathic cases (n=2), and cold urticaria (n=1). Non-steroidal anti-inflammatory drugs (NSAIDs) (44%) and beta-lactams (10%) were the primary culprits. In cases where neither drugs nor venom were involved, food allergies were the cause (P&lt;0.001). With venom allergy, the cause was venom, and without venom, drug allergy was the cause (P&lt;0.001). Female patients showed significantly higher drug- and food-related anaphylaxis rates than males (P=0.032 and P=0.042, respectively). History of Apis mellifera-related anaphylaxis was significantly more common than Vespula vulgaris-related cases (P=0.028). Anaphylaxis severity included grade 2 (30%), grade 3 (48%), and grade 4 (12%) reactions. Recurrent anaphylaxis episodes occurred in 55% (n=42) of patients. Initial hospital administrations involved epinephrine injections in only 25% (n=19) of cases. Cutaneous symptoms were present in 94%, respiratory symptoms in 88%, cardiovascular symptoms in 63%, neurological symptoms in 57%, and gastrointestinal symptoms in 12% of patients. Conclusion: This study identified drug allergy as the leading cause of anaphylaxis in the examined cases. Preventable factors contributing to drug-induced anaphylaxis included insufficient patient and physician knowledge and widespread over-the-counter drug use without medical consultation. Despite 55% of patients experiencing recurrent attacks, only a quarter received epinephrine administration. These findings emphasize the need to educate patients with recurrent anaphylaxis about avoidance strategies and to enhance healthcare providers’ understanding of anaphylaxis treatment.

Annual patterns in the outcomes and post-arrest care for pediatric out-of-hospital cardiac arrest: A nationwide multicenter prospective registry in Japan

AimOut-of-hospital cardiac arrest (OHCA) has a poor prognosis in children; however, the annual patterns of prognosis and treatment have not been fully investigated. MethodsFrom the Japanese Association for Acute Medicine OHCA registry, a multicenter prospective observational registry in Japan, we identified pediatric patients (zero to 17 years old) between June 2014 and December 2019. The primary outcome was one-month survival. We investigated the annual patterns in patient characteristics, treatment, and one-month prognosis. ResultsDuring the study period, 1188 patients were eligible for analysis. For all years, the zero-year-old group accounted for a large percentage of the total population (between 30% and 40%). There were significant increases in the rates of bystander-initiated cardiopulmonary resuscitation (CPR; from 50.6% to 62.3%, p = 0.003), dispatcher instructions (from 44.7% to 65.7%, p = 0.001), and adrenaline administration (from 2.4% to 6.9%, p = 0.014) over time, whereas the rate of advanced airway management decreased significantly (from 17.7% to 8.8%, p = 0.003). The odds ratios for one-month survival adjusted for potential resuscitation factors also did not change significantly (from 7.1% to 10.3%, adjusted odds ratio for one-year increment = 0.98, confidence interval: 0.86–1.11). ConclusionDespite an increase in the rate of bystander-initiated CPR and pre-hospital adrenaline administration, there was no significant change in one-month survival.