Use Of Autoinjectors Research Articles

Epinephrine Auto-Injector Use in Adolescents at Risk of Anaphylaxis: A Qualitative Study in Scotland, UK

M Gallagher, A Worth, S Cunningham-Burley, A Sheikh. Clin Exp Allergy. 2011;41(6):869–877 Adolescents with allergies are at high risk of fatal anaphylactic reactions. The current study explores barriers to epinephrine auto-injector use among at-risk adolescents in Scotland and investigates strategies to improve anaphylaxis management. Twenty-six adolescents aged 13 to 19 years and 28 of their parents participated in this qualitative study. Participants were recruited through school nurses, primary care physicians, allergy specialists, and a patient support group and via a press release. Forty-five adolescents …

Epinephrine Auto-Injector Pandemic

Epinephrine is crucial in the treatment of anaphylaxis. As anaphylaxis frequently occurs in nonmedical settings, use of an epinephrine auto-injector is vital for prompt management. This article provides an overview of the increasing number of epinephrine auto-injector prescriptions and the underlying causes and contributing factors to these rising prescriptions. It also reviews the current indications for prescription of an epinephrine auto-injector, proper use of epinephrine auto-injectors, and the management of unintentional epinephrine injections.

Patient perceptions of epinephrine auto‐injectors: exploring barriers to use

In recent years, government initiatives have proposed that patient self-care should serve as a key resource in response to the anticipated increase in global demand for health care. However, if patients are to be empowered as self-carers, barriers to engagement must be identified and overcome. Anaphylaxis is an increasingly common life-threatening allergic reaction. Patients at risk of anaphylaxis are prescribed epinephrine auto-injectors and play a crucial role in delivering their own care and management of this condition. One key recommendation is that patients routinely carry an epinephrine auto-injector with them and deploy the device when needed. However, only a small proportion of patients that require epinephrine actually receive it. To explore the reasons why patients who have been prescribed epinephrine auto-injectors fail to adhere to self-care and management recommendations. In-depth interviews with 15 adults who have been prescribed epinephrine auto-injectors were carried out to explore the barriers that exist in the provision of effective self-care and management of anaphylaxis. Inconsistent health professional advice, perceived stigma of carrying a 'weapon-like' device, poor device design and limited patient training were identified as barriers to carriage or use. Patients were reluctant to carry devices in public because of perceived and observed stigma and suspicion. They were happy to ignore expiry dates, and some participants were confident that the emergency services would provide them with the appropriate care they needed, and therefore, did not carry the device in urban areas. Improved training of patients, the public and health professionals around both the carriage and use of auto-injectors are areas for urgent attention if improved levels of self-care are to be attained. The design of epinephrine auto-injectors should also receive attention as patients often fail to carry them owing to size and aesthetics.

Management of anaphylaxis in schools: Evaluation of an epinephrine auto-injector (EpiPen®) use by school personnel and comparison of two approaches of soliciting participation.

BackgroundThere has been no large study characterizing selection bias in allergy and evaluating school personnel’s ability to use an epinephrine auto-injector (EpiPen®). Our objective was to determine if the consent process introduces selection bias by comparing 2 methods of soliciting participation of school personnel in a study evaluating their ability to demonstrate the EpiPen®.MethodsSchool personnel from randomly selected schools in Quebec were approached using a 1) partial or 2) full disclosure approach and were assessed on their ability to use the EpiPen® and identify anaphylaxis.Results343 school personnel participated. In the full disclosure group, the participation rate was lower: 21.9% (95%CI, 19.0%-25.2%) versus 40.7% (95%CI, 36.1%-45.3%), but more participants achieved a perfect score: 26.3% (95%CI, 19.6%-33.9%) versus 15.8% (95%CI, 10.8%-21.8%), and identified 3 signs of anaphylaxis: 71.8% (95%CI, 64.0%-78.7%) versus 55.6% (95%CI, 48.2%-62.9%).ConclusionsSelection bias is suspected as school personnel who were fully informed of the purpose of the assessment were less likely to participate; those who participated among the fully informed were more likely to earn perfect scores and identify anaphylaxis. As the process of consent can influence participation and bias outcomes, researchers and Ethics Boards need to consider conditions under which studies can proceed without full consent. Despite training, school personnel perform poorly when asked to demonstrate the EpiPen®.

The prevention and management of anaphylaxis

Abstract Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause death. The incidence of anaphylaxis is increasing. Clinicians are highly likely to encounter a case during their career, hence they need to be equipped to make a diagnosis through taking a thorough history, mast cell tryptase levels and allergy testing. After confirming the allergen trigger, prevention of anaphylaxis is through avoidance of the allergen, optimal management of co-morbidities such as asthma, desensitization and adjuncts such as anti-IgE therapies. The management of anaphylaxis is different in hospital and community settings, but in both the key emphasis is the prompt administration of adrenaline. Patients therefore need to be empowered to manage potential anaphylactic reactions with training in the use of adrenaline auto-injectors and personalized emergency management plans.

Exercise-induced anaphylaxis: an update

<h3>Summary</h3> Exercise-induced anaphylaxis (EIAn) is a rare and potentially fatal syndrome associated with exercise. It is the most serious and potentially life-threatening hypersensitivity phenomenon for athletes of all sports. Food-dependent EIAn (FDEIAn) shares the same symptoms, but ingestion of foods 2–3 h prior to exercise is crucial for its presentation. Attacks may seldom occur also if food ingestion is made 2–3 hours after exercise. Concomitant use of drugs, particularly aspirin and non-steroidal anti-inflammatory drugs, can worsen the clinical presentation. Clinical manifestations cover a wide range of symptoms, from pruritus to dyspnoea to vascular collapse. Differential diagnoses must be investigated when symptoms are unusual. Several pathogenetic theories have been formulated but the rarity of EIAn has not facilitated the efforts of scientists to find pathophysiological and immunological mechanisms that may account for these conditions. Diagnosis is mainly clinical and can be difficult. Validated protocols including skin prick testing together with food–exercise challenges, laboratory investigations looking for specific immunoglobulin E or through allergy molecular diagnostics are often required. Preventative measures are of fundamental importance, in particular regarding education of patients, family/carers, trainers and teammates. Use of adrenaline autoinjectors is also fundamental and their correct use must be taught to patients, doctors and nurses. Pharmacological preventative measures are not supported by sufficiently powered studies. Further research will be needed to investigate deeper the complexities of EIAn.

Timing the transfer of responsibilities for anaphylaxis recognition and use of an epinephrine auto-injector from adults to children and teenagers: pediatric allergists' perspective

BackgroundThe optimal time for transferring responsibilities for anaphylaxis recognition and epinephrine auto-injector use from adults to children and teenagers has not yet been defined. ObjectiveTo determine whether pediatric allergists have age-specific goals for beginning to transfer responsibilities for anaphylaxis recognition and epinephrine auto-injector use from parents and caregivers to children and teenagers at risk of anaphylaxis in the community. MethodsMembers of the American Academy of Pediatrics Section on Allergy and Immunology (AAP-SOAI) were surveyed about when they typically begin to transfer these responsibilities from adults to children and teenagers. ResultsEighty-eight allergists responded to the survey, 97.7% of whom provided service to children and teenagers with food allergies. Few allergists expected to begin transferring responsibilities for anaphylaxis recognition and epinephrine auto-injector use to children younger than 9 to 11 years. By the time their patients reached age 12 to 14 years, however, most allergists expected them to be able to describe some anaphylaxis symptoms (95.4%), demonstrate how to use an epinephrine auto-injector trainer (93.1%), begin carrying self-injectable epinephrine (88.2%), recognize the need for epinephrine (88.1%), learn to self-inject epinephrine (84.5%), and be able to self-inject epinephrine (78.6%) (cumulative data). The allergists rated the following as “very important” readiness factors for beginning to transfer responsibilities: medical history, developmental level, and ability to demonstrate auto-injector technique. ConclusionMost pediatric allergists expected that by age 12 to 14 years, their patients should begin to share responsibilities with adults for anaphylaxis recognition and epinephrine auto-injector use; however, they individualized the timing based on assessment of patient readiness factors.

At What Age Should Children and Teenagers Be Able To Recognize Anaphylaxis and Self-Inject Epinephrine?

To determine if pediatric allergists have age-specific goals for timing the transfer of responsibilities for anaphylaxis recognition and epinephrine auto-injector use from adults to children and teenagers at risk of anaphylaxis in the community.

Epinephrine Auto-injector Use In Children At Risk Of Food-induced Anaphylaxis: Is It Used Appropriately?

Epinephrine Auto-injector Use In Children At Risk Of Food-induced Anaphylaxis: Is It Used Appropriately?

The use of adrenaline autoinjectors by children and teenagers

Although adrenaline is recommended as first line treatment for anaphylaxis, it is often not utilized. There has been a debate about when adrenaline autoinjectors should be prescribed and how many should be dispensed. To see how many adrenaline autoinjectors were used during anaphylactic reactions and to determine why they were not used in situations where they were clinically indicated. Patients were recruited prospectively at 14 paediatric allergy clinics throughout UK. Participants completed a questionnaire covering demographic data, atopic status and details of allergic reactions in the previous year and reasons for using more than one device. A total of 969 patients were recruited of whom 466 (48.1%, 95% CI: 37.9-58.2) had had at least one reaction in the previous year; 245 (25.3%, 95% CI: 16.2-34.4) of these reactions were anaphylaxis. An adrenaline autoinjector was used by 41 (16.7%, 95% CI: 11.7-21.3) participants experiencing anaphylaxis. Thirteen participants received more than one dose of adrenaline, for nine of these a health professional gave at least one. The commonest reasons for using more than one were severe breathing difficulties (40%), lack of improvement with first dose (20%) and miss-firing (13.3%). The commonest reasons for not using adrenaline in anaphylaxis were 'thought adrenaline unnecessary' (54.4%) and 'unsure adrenaline necessary' (19.1%). Many with wheeze did not use their autoinjector. Adrenaline is used by only a minority of patients experiencing anaphylaxis in the community. Thirteen of the 41 patients with anaphylaxis who used their autoinjector needed another dose of adrenaline. Further research is needed to consider how to best encourage the usage of adrenaline when clinically indicated in anaphylaxis.

A Case of Accidental Injection of Epinephrine (Epipen)

Prompt injection of epinephrine is of fundamental importance in the treatment of systemic anaphylaxis (1). For the prehospital treatment of anaphylaxis, epinephrine autoinjectors in the form of Epipen® are commonly recommended, because they provide advantages of an easy-to-use, sterile, premeasured single dose delivery. Side effects may include increased heart rate and stronger or irregular heartbeat. We present a case which developed an atrial fibrillation with rapid ventricular response following accidental delivery of epinephrine through Epipen injection. A previously healthy 44 year old male patient admitted to the emergency department (ED) complaining of rapid heart beat. During the history taking, patient stated he accidentally injected his left thumb with epinephrine (Epipen® 0.3 ml 0.3 mg 1/1000), which was prescribed for one of his relatives, 15 minutes prior to the ED visit. Patient complained of headache, widespread numbness and rapid heart beat. On physical exam, patient was found to be fully alert and oriented, with blood pressure of 120/80 mmHg, pulse 147 bpm, temperature 36°C. His heart sounds were normal and other systemic exam revealed no abnormality. His initial EKG showed atrial fibrillation with rapid ventricular response at a rate of 145. 5 mg metoprolol was administered, which caused the cardiac rhythm to turn into normal sinus. Patient was observed for 12 hours during which time he had no other episode of tachycardia and his cardiac enyzme values turned out to be normal. Patient was dischared with instructions. Epinephrine auto-Injectors are used for the emergency treatment of severe allergic reactions, by the patients who are at increased risk for these reactions. Side effects may include increased heart rate, stronger or irregular heartbeat, sweating, difficulty breathing, dizziness, headache, nervousness, or anxiety (2). These side effects usually go away quickly, especially if patients rest. For patients experiencing high blood pressure, overactive thyroid, heart disease, these side effects may present more severe or last longer. Other side effects of accidental injection of epinephrine severe pain on the injection side even due to severe local vasoconstriction (3). Our patient did not experience any of the complications stated here, but instead he experienced cardiac side effects. The atrial fibrillation with rapid ventricular response turned to normal sinus rhythym following the administration of single dose of beta blocker. As a result, emergency physicians who are concerned about the proper use of epinephrine autoinjectors should receive adequate instruction on their use and potential side effects.

Make‐up of the epinephrine autoinjector: the effect on its use by untrained users

Part of the problems related to proper use of the epinephrine autoinjector may be related to the design of the autoinjector itself. We investigated whether minor modifications in the design of the currently available epinephrine autoinjector ease its use and abrogate common use errors. All interns other than those who had previously worked in allergy department in a medical school were invited to the study. Two identical epinephrine autoinjector trainers (Epipen trainer(®) ) were used, one of which was modified by changing the gray safety cap to red and placing a yellow arrow pointing to the black injection tip. A written and visual instruction sheet for each trainer was provided. Participants were asked to demonstrate the use of the Epipen trainer either with the original or with the modified one. They were scored and timed for their demonstration. Out of the 224 interns who were invited to participate, one hundred and sixty-four interns (73.2%) participated in the study. The number of participants correctly demonstrating the use of epinephrine autoinjectors was 22.6% and 65% in unmodified and modified trainer groups, respectively (p < 0.001). The mean time to administer trainers was 26.78 ± 10.6 and 15.88 ± 2.55 s; total median scores were 3.08 ± 1.48 and 4.47 ± 0.84 in unmodified and modified groups, respectively (p < 0.001 for both). Significantly fewer participants had presumptive unintentional injection injury while using modified (5%) compared with unmodified trainer (45.2%) (p < 0.001). Few and simple modifications in the design of epinephrine autoinjector were found effective in increasing its correct use and decreasing common use errors by untrained users. (Clinical trials identifier: NCT01217138).

Epinephrine autoinjector availability among children with food allergy

Epinephrine is the treatment of choice for anaphylaxis. Delay in administration of epinephrine is a known risk factor for food allergy reaction-related mortality; however, individuals with food allergy may not have epinephrine readily available. This study was designed to determine the percent of food-allergic children that have an epinephrine autoinjector readily available and factors associated with epinephrine autoinjector carriage rates. Parents completed a questionnaire on food allergy and food allergy preparedness. Staff recorded whether an epinephrine autoinjector and medical alert bracelet was immediately available in clinic. Parental responses from 63 food-allergic children were included. Fifty-nine percent (37/63) had an epinephrine autoinjector present in the clinic, and 79% (50/63) reported receiving training in epinephrine autoinjector use. There was no correlation between epinephrine autoinjector presence in the clinic and parental report of having an epinephrine autoinjector available at all times (phi = 0.21). Epinephrine autoinjector training was associated with increased odds of having an epinephrine autoinjector immediately available (adjusted odds ratio, 8.74 [1.69, 45.04]). Fewer school aged children (≥5 years old) reportedly had their epinephrine autoinjector with them when eating lunch (25% [8/32] versus 42% [13/31]; p = 0.002) or snacks (28% [9/32] versus 37% [13/31]; p = 0.005) when compared with those <5 years old. Many children do not have their epinephrine autoinjectors readily available despite parental report. Epinephrine autoinjector training improved the odds of having an epinephrine autoinjector readily available. Continued patient education on the importance of having an epinephrine autoinjector easily accessible, especially when eating, is important.

Training of trainers on epinephrine autoinjector use

The majority of physicians do not know how to use epinephrine autoinjectors. This displays that current education of physicians on anaphylaxis is inadequate for a thorough practice. We hypothesize that a theoretical lecture together with a practical session on epinephrine autoinjector use will improve its proper use by physicians. Residents, specialists, and consultants from General Pediatrics excluding allergists and allergy fellows were included in this study. All physicians were given an eight-item questionnaire followed by a practical session scoring and timing ability to use epinephrine autoinjector trainer. This ensued with one-to-one hands-on training on correct autoinjector use. Finally, a joint theoretical lecture on anaphylaxis including re-demonstration of epinephrine autoinjector use was given. All physicians were scored a second time on use of epinephrine autoinjector 6 months later. One hundred fifty-one of 196 participants completed all steps of the study in four tertiary hospitals. Correct use of epinephrine autoinjector improved from 23.3% to 74.2%, mean score from 3.49 ± 1.14 to 4.66 ± 0.65, need for prospectus from 91.4% to 29.1%, and mean time to administer autoinjector from 28.01 ± 6.22 s to 19.62 ± 5.01 s (p < 0.001 for each). The rate of most common mistakes during autoinjector use decreased but the ranking did not change. An integrated theoretical and practical education increased correct of epinephrine autoinjector use by physicians. Ongoing mistakes despite this education may be related with its design.

What are the ‘ideal’ features of an adrenaline (epinephrine) auto-injector in the treatment of anaphylaxis?

Anaphylaxis is a systemic allergic reaction that often involves respiratory symptoms and cardiovascular collapse, which are potentially life-threatening if not treated promptly with intramuscular adrenaline. Owing to the unpredictable nature of anaphylaxis and accidental exposure to allergens (such as peanuts and shellfish), patients should be prescribed intramuscular adrenaline auto-injectors and carry these with them at all times. Patients also need to be able to use their auto-injectors correctly while under high stress, when an anaphylactic attack occurs. Despite this, an alarming number of patients fail to carry their auto-injectors and many patients, carers of children with known anaphylaxis and healthcare professionals do not know how to use the device correctly, despite having had training. Currently available auto-injector devices have various limitations that may impede their use in the management of anaphylaxis. There is also a lack of validated assessment criteria and regulatory requirements for new devices. This review describes the different delivery systems used in currently available auto-injectors and discusses the key barriers to the use of adrenaline auto-injectors, with the goal of identifying the 'ideal' features/characteristics of such devices in the emergency treatment of anaphylaxis that will ensure ease of use, portability and accurate delivery of a life-saving drug.

Epinephrine and its use in anaphylaxis: current issues

Epinephrine is a life-saving medication in the treatment of anaphylaxis, in which it has multiple beneficial pharmacologic effects. Here, we examine the evidence base for its primary role in the treatment of anaphylaxis episodes in community settings. We review the practical pharmacology of epinephrine in anaphylaxis, its intrinsic limitations, and the pros and cons of different routes of administration. We provide a new perspective on the adverse effects of epinephrine, including its cardiac effects. We describe the evidence base for the use of epinephrine in anaphylaxis. We discuss the role of epinephrine auto-injectors for treatment of anaphylaxis in community settings, including identification of patients who need an auto-injector prescription, current use of auto-injectors, and advances in auto-injector design. We list reasons why physicians fail to prescribe epinephrine auto-injectors for patients with anaphylaxis, and reasons why patients fail to self-inject epinephrine in anaphylaxis. We emphasize the primary role of epinephrine in the context of emergency preparedness for anaphylaxis in the community. Epinephrine is the medication of choice in the first-aid treatment of anaphylaxis in the community. For ethical reasons, it is not possible to conduct randomized, placebo-controlled trials of epinephrine in anaphylaxis; however, continued efforts are needed towards improving the evidence base for epinephrine injection in this potentially fatal disease.

Epinephrine auto-injector use and demographics in a Veterans Administration population

The epinephrine auto-injector has been widely used over a long period of time. Certain aspects of this therapy and demographic data, however, have not been well studied. This study investigates patient use and understanding of epinephrine auto-injector use. As part of an ongoing quality assurance program, we evaluated 66 patients who had been given an epinephrine auto-injector and followed in the Allergy and Immunology Clinics at the West Los Angeles Veterans Medical Center. Data analyzed included patient demographics, medical indications for epinephrine auto-injector prescriptions, and the patient's understanding and use of the device. The mean age of our patients was 50 years. There were 44 men (66.7%) and 22 women (33%). Twenty-three patients were prescribed epinephrine auto-injector for adverse food reactions. Ninety-two percent (92%) of the patients knew how to use their epinephrine auto-injector properly, however, only 58% carried their device with them consistently. Of the patients, 91% understood why the auto-injector was prescribed. Of the total patients prescribed epinephrine auto-injector, 79% refilled their medication before the 1 year expiration date. Only 12% of the patients studied had required the use of their auto-injector. Most patients knew how and when to administer their epinephrine auto-injector. Despite detailed instructions in a specialty clinic only a slight majority carried it consistently. These data clearly indicate that further patient education or other measures are needed to improve compliance and effective use.

Severe Contrast Reaction Emergencies: High-fidelity Simulation Training for Radiology Residents and Technologists in a Children's Hospital

<h3>Rationale and Objectives</h3> Severe reactions to radiographic contrast agents can be life threatening, and although they are rare, effective recognition and management are essential to improving outcomes. A high-fidelity radiology simulation course for radiology residents and technologists focusing on severe contrast reactions and immediate treatments was designed to test the hypothesis that knowledge would improve with this educational intervention. <h3>Materials and Methods</h3> A prospective pretest and posttest study design was used. Residents and technologists worked in teams of three to five members. Learning objectives focused on demonstrating when and how to use basic life support skills and epinephrine auto-injectors. Each resident and technologist was administered a pretest prior to the start of the case scenarios and a posttest following the debriefing session. Scores from the pretest and posttest for the residents and technologists were compared using a paired-samples <i>t</i> test. <h3>Results</h3> Nineteen radiology residents and 11 radiology technologists participated. The average test scores were higher and improved significantly following the simulation experience for both the radiology residents (57% vs 82%, <i>P</i> < .001) and technologists (47% vs 72%, <i>P</i> = .006). Anonymous evaluations demonstrated that the experience was well received by residents and technologists, with 97% of learners (29 of 30) rating the experience as extremely or very helpful. Important learning themes included the knowledge of epinephrine auto-injector use and basic life support skills. <h3>Discussion</h3> High-fidelity simulation for radiology residents and technologists focusing on epinephrine auto-injector use and basic life support skills during the first 5 minutes of a severe contrast reaction can significantly improve recognition and knowledge in treating patients having severe contrast reactions.

Epipen Demographics and Use in a V.A. Population

RATIONALE: Epinephrine auto injector (Epi-pen) use and demographic data have not been studied in a VA population. This study investigates utilization and patient's understanding of Epi-pen use in this population.

A comparison of 4 epinephrine autoinjector delivery systems: usability and patient preference

Prefilled epinephrine autoinjectors are sometimes improperly used by patients, caregivers, and physicians. A user-centered design process led to the development of 2 prototype epinephrine autoinjectors (INT01 and INT02) that have a unidirectional perceived injection end, a self-retracting needle, and, with INT02, voice instructions to assist in guiding users through administration. To compare the usability and patient preference among 4 epinephrine autoinjectors: EpiPen, TwinJect, INT01, and INT02. A total of 48 participants were divided equally among 3 age groups: 7 to 10, 11 to 15, and 16 to 55 years. In each group, half had prior TwinJect or EpiPen training. In 1-hour sessions, without training, participants performed simulated-use testing under observation for all 4 epinephrine delivery systems. Usability (i.e., the ability to perform the manufacturer's labeled instructions), task completion time, and preferences were assessed and analyzed based on device, age, previous experience, sex, device malfunction, and testing order. More participants correctly followed all device instructions with INT02 (22 [46%]) than with INT01 (13 [27%]), EpiPen (6 [12%]), or TwinJect (0 [0%]). The difference among devices was significant (P < .01) after adjusting for device malfunctions and age group (the youngest age group [those aged 7-10 years] performed significantly worse than the other 2 groups). Prior experience, sex, and testing order did not significantly affect this measure. The first choice of overall preference was greater (P < .001) for INT02 (35 participants [73%]) vs. INT01 (7 participants [15%]), EpiPen (5 participants [10%]), and TwinJect (1 participant [2%]). The user-centered device design may have a significant impact on correct epinephrine autoinjector use and patient preference.