Biphasic Anaphylactic Reactions Research Articles

DELAYED, PERSISTENT ANAPHYLAXIS AFTER AN ALLERGY INJECTION

<h3>Introduction</h3> Delayed or biphasic anaphylactic reactions are rare. We report a delayed onset, prolonged anaphylactic reaction which occurred twelve hours after the first dose of allergen immunotherapy. <h3>Case Description</h3> 35 year-old male with allergic rhinoconjunctivitis and many positive serum aeroallergen tests initiated allergen immunotherapy for severe persistent symptoms despite treatment with Fluticasone, Cetirizine, and Azelastine. Twelve hours after his first allergy injection, he developed pruritus, took a diphenhydramine and went to sleep. When he awoke the next morning, his spouse noted that his face, back, and chest were erythematous and the pruritus continued. He had scattered urticaria as well. He developed wheezing 24 hours after the injection and then again approximately 72 hours later which he treated with an Albuterol MDI. He did not seek medical attention at any point, but took diphenhydramine which only helped temporarily. He notes that he just "ignored the symptoms." He had an Epi pen in his possession but did not use it. The itching and rash persisted for approximately ten days and the wheezing remitted within five. Allergy injections were not reinitiated. <h3>Discussion</h3> This is an example of late-onset anaphylaxis which lasted greater than a week, likely due to lack of appropriate medical treatment. It is important to educate our immunotherapy patients on the signs of anaphylaxis as well as the possibility that though rare, symptoms can be delayed. In addition, it is important to emphasize the need for prompt medical attention in such situations.

Peri-Operative Anaphylaxis - Antiquated Customs and News Towards the Culprits

Perioperative anaphylaxis occurs in about 1:6000 of all surgical procedures. Recently, the pathophysiology of anaphylactic reactions via mast cell related G-protein und complement-activated pseudo-allergy have been added to the "old" IgE mediated etiology. New culprits for anaphylactic reactions are chlorhexidine or gelatine as hemostypticum or blue surgical dyes to mark the situs. Biphasic anaphylactic reactions should be kept in mind. In the meantime, propofol use is allowed in egg and soybean allergic patients.

Peanut anaphylaxis in 2022: Decoupling epinephrine usage from emergency department evaluation

Peanut anaphylaxis in 2022: Decoupling epinephrine usage from emergency department evaluation

Incidence and timing of biphasic anaphylactic reactions: a retrospective cohort study.

AimWe investigated the frequency of overall biphasic reactions, biphasic reactions that met the diagnostic criteria of anaphylaxis, and biphasic reactions that caused a severe abnormality in vital signs in patients who visited the emergency department of a tertiary hospital.MethodsThis retrospective cohort study included patients aged 18 years or over who presented with anaphylaxis at the emergency department of a tertiary care hospital between January 2014 and December 2016. The primary outcome was the incidence of biphasic reactions that caused a severe abnormality in vital signs and developed within 7 days. Secondary outcomes were the frequency of overall biphasic reactions and those that met the diagnostic criteria of anaphylaxis.ResultsIn total, 437 patients aged over 18 years visited the emergency department during the study period. Among them, 202 were enrolled in this study. The proportion of patients who had overall biphasic reactions, those that met the diagnostic criteria of anaphylaxis, and those with a severe abnormality in vital signs was 8.9%, 3.0%, and 1.0%, respectively. Overall, 32.7% of patients were hospitalized, but hospitalization aided in the treatment of severe biphasic reactions at the early stage in only one patient.ConclusionWe found that 8.9% of adult patients with anaphylaxis had a biphasic reaction, but biphasic reactions together with severe abnormalities in vital signs were rare.

Characteristics of Anaphylactic Reactions: A Prospective Observational Study in Japan.

Anaphylaxis is a systemic, life-threating, allergic reaction in which the clinical features may vary in different populations or due to the allergic triggers. Moreover, the timing and characteristics of biphasic anaphylactic reactions remain unclear. The purpose of this study was to investigate the clinical characteristics of anaphylaxis cases assessed and treated in Japanese hospitals. This was a prospective observational study of anaphylactic reactions treated in the Emergency Department (ED) of two medical centers from June 2016 to May 2019. All patients diagnosed with anaphylaxis were enrolled in this study. Data collected included patient demographics, symptoms and signs, treatment, clinical course, and suspected triggers. Descriptive statistics and univariate methods were used in the analyses. We enrolled 302 patients. The median age was 32years (interquartile range 13-37) and the sample included 182 (60.3%) women. Of the 302 patients, 179 (59.3%) had a history of allergic reactions. The dermatologic, respiratory, gastrointestinal, and cardiac systems were involved in 297 (98.3%), 248 (82.1%), 150 (49.7%), and 55 (18.2%), respectively. Nineteen patients (6.3%) experienced biphasic anaphylactic reactions. Epinephrine use was associated with a lower incidence of biphasic anaphylactic reaction (odds ratio 0.3, 95% confidence interval 0.1-0.9). Time to recurrence of symptoms ranged from 2 to 48h (median: 10h). In this prospective ED study, foods were the most common triggers of anaphylaxis, and epinephrine administration was associated with a decreased occurrence of biphasic anaphylactic reactions. Over half of patients experiencing biphasic anaphylactic reactions developed symptoms more than 10h after presentation.

A biphasic anaphylactic reaction during plasmapheresis in a non-atopic patient with Guillain-Barré syndrome

A biphasic anaphylactic reaction during plasmapheresis in a non-atopic patient with Guillain-Barré syndrome

MP55: Characteristics associated with biphasic reactions in an adult population

Introduction: Biphasic anaphylactic reactions are a concern in emergency medicine. Risk factors associated with this type of reaction remain ill-defined. The aim of this study was to investigate elements associated with biphasic anaphylactic reactions and to determine the impact of anaphylaxis treatments on biphasic reactions. Methods: From the multicenter Cross-Canada Anaphylaxis Registry prospective cohort, we selected adults (≥18 years) with a visit to the emergency department (ED) of Sacré-Cœur Hospital, an urban tertiary-care hospital. Then, a structured chart review was done to collect additional information on types and timing of treatments for the initial anaphylactic reaction, presence and treatment of biphasic reactions during the initial ED visit or upon patients’ return. Biphasic reactions were defined by the recurrence of any anaphylaxis symptoms within 72 hours of a resolved anaphylaxis episode. Potential factors associated with biphasic reactions were studied using Chi-Square and Mann-Whitney tests. Results: Patients with anaphylaxis were enrolled between April 2014 and February 2018. From the cohort, 401 adult patients were identified. We found 37 patients who developed a biphasic reaction. Amongst them, 33 received treatments and 9 required more than one dose of intramuscular epinephrine. None of the biphasic reaction patients required intravenous epinephrine, other vasopressors, ICU admission, or endotracheal intubation. Biphasic reactions appeared in a median time of 13.3h after the initial reaction ranging from 1.1h to 69.6h (IQR 30.2). There was no difference in age or gender of patients who developed a biphasic reaction compared those who did not. Pertinent past medical history, daily medications, mean of arrival to the ED, allergen type, ingestion route, or initial symptoms during the anaphylaxis episode were not significantly different in the two groups. Treatment with corticosteroids was similar in the two groups (9.0% vs. 8.1% p = 0.82). Treatment, dose and route of administration of epinephrine was not different in the two groups but longer delays before treatment with the first dose of epinephrine was more frequent in biphasic reaction patients (median delay of 64 minutes, p = 0.015). Conclusion: No patient characteristic, allergen, route of ingestion, symptom, nor treatment with corticosteroids has shown to be significantly different in patients with and without biphasic reactions. Delayed treatment with epinephrine is significantly associated with biphasic reactions.

Further Evaluations of Factors That May Predict Biphasic Reactions in Emergency Department Anaphylaxis Patients

S Lee, A Peterson, CM Lohse, EP Hess, RL Campbell. J Allergy Clin Immunol Pract. 2017;5(5):1295–1301 To evaluate variables to help in the identification of patients who are at an increased risk for biphasic anaphylactic reactions in the emergency department (ED). The study included 807 patients in the ED with a total of 872 ED visits for anaphylaxis. The median age was 34 years, with 58% female patients and 26% pediatric subjects <18 years of age. Food was the most common inciting trigger in 35% of patients, followed by drugs in 20% of patients and venom in 12% of …

Acute respiratory distress syndrome following a biphasic anaphylactic reaction to morphine: a case report and review of the literature

Background: Biphasic anaphylactic reaction is a variant of the usual and more commonly seen monophasic anaphylactic reaction. However, recently it has been observed that biphasic anaphylactic react...

Conhecimento de pediatras que atuam em urgências e emergências sobre tratamento da anafilaxia

Introdução: Anafilaxia é uma reação sistêmica grave, aguda e potencialmente fatal. Apresenta vários desencadeantes e mecanismos diferentes, entretanto, o tratamento agudo é igual em todos os casos. Objetivo: Avaliar o conhecimento sobre tratamento da anafilaxia e choque anafilático (CA) de pediatras que atuam em setor de emergência pediátrica. Métodos: Estudo transversal através da aplicação de questionário de múltiplas escolhas com 10 perguntas sobre tratamento da anafilaxia e CA. Foram convidados todos os pediatras do Pronto Socorro de um Hospital Público Pediátrico. Resultados: Cinquenta entre 51 pediatras concordaram em participar do estudo. A média de acertos foi 6,32 com mediana de 7 (mínimo 2 e máximo 10). Houve reconhecimento adequado dos pediatras sobre a droga de escolha para iniciar o tratamento da anafilaxia e CA em 96% e 92%, respectivamente. Sobre a via de administração da adrenalina, a adequação das respostas foi de 64%. Em relação à dose de adrenalina, 70% identificaram corretamente, porém, o conhecimento sobre a dose máxima foi de 44%. Ao perguntar o intervalo para repetir a adrenalina, 38% responderam corretamente. Perguntou-se sobre terapias adjuvantes no tratamento do CA com 74% de acerto. Sobre a droga que previne a reação anafilática bifásica, 60% responderam corretamente. Quanto ao tempo de observação, 54% responderam o período adequado. O acerto sobre apresentações disponíveis de adrenalina autoinjetável foi de 40%. Conclusão: Houve dificuldade principalmente em reconhecer dose máxima, dose de adrenalina autoinjetável e tempo necessário para ser repetida, o que aumenta o risco de superdosagem e seus efeitos adversos.

Do Corticosteroids Prevent Biphasic Anaphylaxis?

Anaphylaxis is a severe hypersensitivity reaction that is rapid in onset and can result in death. The pattern of an anaphylactic reaction can be uniphasic (or monophasic), biphasic (also called delayed or late phase), or refractory in nature. The most widely cited definition of biphasic anaphylaxis is a recurrence of anaphylactic symptoms after initial resolution despite no further exposure to the trigger. Corticosteroids are thought by some to prevent the development of biphasic symptoms and, therefore, commonly used in the emergency treatment of anaphylaxis but this has not been systemtically analyzed. In this review, Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus were searched for articles using "anaphylaxis" combined with the key terms "biphasic" and/or "corticosteroids" and/or "epinephrine." A total of 31 appropriate studies were identified. Biphasic anaphylactic reactions are more likely to occur in moderate to severe anaphylaxis or when anaphylaxis is not treated with timely epinephrine. Because of the potential detrimental adverse effects of corticosteroids and lack of compelling evidence demonstrating an effective role in reducing anaphylaxis severity or preventing biphasic anaphylaxis, we do not advocate for their routine use in anaphylaxis.

Corticosteroids in management of anaphylaxis; a systematic review of evidence.

As anaphylaxis is a medical emergency, there are no randomized controlled clinical trials on its emergency management. Therefore, current guidelines are mostly based on data from observational studies, animal and laboratory studies. Although epinephrine is the mainstay of recommended treatment, corticosteroids are also frequently used. This review evaluates the evidence on the use of corticosteroids in emergency management of anaphylaxis from published human and animal or laboratories studies. Thirty original research papers were found with 22 human studies and eight animal or laboratory studies. The average rate of corticosteroid use in emergency treatment was 67.99% (range 48% to 100%). Corticosteroids appear to reduce the length of hospital stay, but did not reduce revisits to the emergency department. There was no consensus on whether corticosteroids reduce biphasic anaphylactic reactions. None of the human studies had sufficient data to compare the response to treatment in different treatment groups (i.e. corticosteroids, epinephrine, antihistamines). Animal studies demonstrated that corticosteroids act through multiple mechanisms. These modulate gene expression, with effects becoming evident 4 to 24 hours after administration. A much quicker response has been detected within 5 to 30 minutes, through blockade of signal activation of glucocorticoid receptors independent of their genomic effects. Therefore, we conclude that there is no compelling evidence to support or oppose the use of corticosteroid in emergency treatment of anaphylaxis. However, based on the available data, it appears to be beneficial and there was no evidence of adverse outcomes related to the use of corticosteroids in emergency treatment of anaphylaxis.

Staphylococcus aureus effusive constrictive pericarditis complicated by right coronary artery mycotic aneurysm and right ventricular infarction

Anaphylaxis is a severe hypersensitivity reaction that is rapid in onset and can result in death. The pattern of an anaphylactic reaction can be uniphasic (or monophasic), biphasic (also called delayed or late phase), or refractory in nature. The most widely cited definition of biphasic anaphylaxis is a recurrence of anaphylactic symptoms after initial resolution despite no further exposure to the trigger. Corticosteroids are thought by some to prevent the development of biphasic symptoms and, therefore, commonly used in the emergency treatment of anaphylaxis but this has not been systemtically analyzed. In this review, Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus were searched for articles using “anaphylaxis” combined with the key terms “biphasic” and/or “corticosteroids” and/or “epinephrine.” A total of 31 appropriate studies were identified. Biphasic anaphylactic reactions are more likely to occur in moderate to severe anaphylaxis or when anaphylaxis is not treated with timely epinephrine. Because of the potential detrimental adverse effects of corticosteroids and lack of compelling evidence demonstrating an effective role in reducing anaphylaxis severity or preventing biphasic anaphylaxis, we do not advocate for their routine use in anaphylaxis.

Deadly Envenomation by Massive Bee Stings in a 7-Year Old Child in Ouagadougou

Introduction: We are reporting a deadly case of massive bee stings observed in a 7-year-old child in Ouagadougou. Observation: The first symptoms, which appeared two hours after the stings of about 200 bees, motivated a consultation in a nearby dispensary in which the child received intravenous betamethasone before being referred to the University Hospital Center Yalgado Ouedraogo (CHUYO). Seven hours after the accident, a rapid deterioration in the general condition was noted with hemorrhage, respiratory distress, coma, and shock. A grade 3 anaphylaxis was diagnosed. The patient didn’t survive despite of the cardiopulmonary resuscitation using adrenaline in intensive care. Conclusion: The massive bee stings have caused a severe biphasic anaphylactic reaction which could not be reversed by the adrenaline administered in the second phase. The development of a protocol would contribute to a better management of the cases.

Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-analysis

A biphasic reaction is a potentially life-threatening recurrence of symptoms after initial resolution of anaphylaxis without re-exposure to the trigger. The infrequent nature of these reactions has made them difficult to study and predict. The aim of this study was to evaluate the time of onset and predictors of biphasic anaphylactic reactions. Original research studies that described biphasic reactions in case series or cohort studies were included. Studies that did not describe biphasic reactions and case series with less than 2 biphasic reactions were excluded. Data sources included MEDLINE, EMBASE, Web of Science, and Scopus from inception to January 2014 and bibliographies of included articles. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous variables. Inconsistency among studies was assessed with the I(2) statistic. Twenty-seven observational studies that enrolled 4114 patients with anaphylaxis and 192 patients with biphasic reactions were included. The median time of symptom onset was 11 (range 0.2 to 72.0) hours. Food as the inciting trigger was associated with decreased risk (pooled OR 0.62, 95% CI: 0.4 to 0.94, I(2)= 0%) and an unknown inciting trigger with increased risk (pooled OR 1.72, 95% CI: 1.0 to 2.95, I(2)= 61%). Initial presentation with hypotension (pooled OR 2.18, 95% CI: 1.14 to 4.15, I(2)= 79%) was also associated with the development of a biphasic reaction. Biphasic anaphylatic reactions were less likely among patients with food as an inciting trigger. Patients who present with hypotension or have an unknown inciting trigger may be at increased risk of a biphasic reaction. Clinicians should tailor observation periods for patients individually based on clinical characteristics.

Incidence of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-Analysis

Incidence of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-Analysis

Anaphylaxis in the emergency room in the city of São Paulo: do we know how to manage?

Results Out of 177 physicians invited to take part of the survey, only 77 accepted. Out of which, 48,1% have already treated an anaphylactic reaction. Eventhough 49% deny ever having attended a case, they claim having treated of alergy set on more than one organic system. As a non-pharmacologic measure, the most mentioned was oxygen. As a pharmacologic measure, adrenalin was the choice of 69% of physicians, also mentioning the intramuscular pathway only by 51,85%. Corticosteroids were chosen as a consecution for the initial therapy by 19,6%. Glucagon was elected by four physicians as an alternative therapy for the management of a refractory anaphylactic reaction in patients in cronic use of beta blockers. Out of the 77 doctors, 16 (20,77%) already heard of biphasic anaphylactic reactions, while 79,23% had no acknowledgement.

Abstract 154: Continuous Intravenous Administration of Adrenaline May Prevent the Biphasic Reaction of Anaphylaxis

Objective: Anaphylaxis is a multi-system syndrome resulting from the release of chemical mediators upon exposure to an allergen. Biphasic anaphylactic reactions may occur due to secondary elevation of the chemical mediators following the initial reaction. The initial treatment of anaphylaxis generally includes adrenaline injection, which results in decreased chemical mediator release. We hypothesize that continuous intravenous administration, rather than intramuscular injection of adrenaline, may inhibit the release of chemical mediators following the initial reaction, and thereby prevent biphasic reactions. Accordingly, in this study, we aimed to investigate the occurrence of biphasic reactions according to the type of administration of adrenaline. Methods: We included patients with anaphylaxis admitted to our hospital, who were treated with adrenaline between April 2005 and March 2014. We retrospectively investigated the occurrences of biphasic reactions after admission in patients treated with continuous intravenous adrenaline or intramuscular adrenaline injections. Patients were excluded if they had received intravenous bolus or complex methods of administration. The risk of biphasic reactions according to the method of administration was analyzed by logistic regression. Results: A total of 104 patients were included in the study (continuous intravenous administration: 56, intramuscular injection: 48). Eight patients (7.69%) experienced biphasic reactions, out of which one had received continuous intravenous administration, and seven had received intramuscular injection (p = 0.02). No patient had received adrenaline during the biphasic reaction in the continuous intravenous administration group compared to the three patients in the intramuscular injection group (p = 0.10). Logistic regression analysis revealed that the odds ratio of biphasic reactions for continuous intravenous administration vs. intramuscular injection of adrenaline was 0.11 (p = 0.04, 95% confidence interval: 0.01-0.90). Conclusions: Continuous intravenous administration of adrenaline may prevent the biphasic reaction of anaphylaxis.

34 Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-Analysis of the Literature

34 Time of Onset and Predictors of Biphasic Anaphylactic Reactions: A Systematic Review and Meta-Analysis of the Literature

Biphasic anaphylactic reactions: occurrence and mortality.

Monitoring after complete resolution of anaphylactic reactions is recommended. The aim of this study was to define the occurrence of biphasic - and clinically important biphasic - anaphylactic reactions, the number of transfers to intensive care units (ICU) because of anaphylaxis, and the number of deaths within 10 days of presentation to the emergency department (ED). Clinical records of patients visiting the ED of a tertiary care hospital were analysed retrospectively. Hospital databases, direct contact with patients and caregivers, and the Internet were used to obtain mortality rates. Of 259 557 ED presentations from February 2001 through to August 2013, 1334 (0.51%) episodes of allergic reactions were detected, and 532 (0.20%) episodes in 495 patients fulfilled the definition of anaphylaxis. In 227 (44.8%) episodes, the length of hospital stay was ≥8 h (median 22 h, IQR 16-24). There were 507 uniphasic and 25 (4.5%) biphasic anaphylactic reactions. Twelve (2.3%) were clinically important, including 2 (0.36%) that occurred during hospital stay, one of whom (0.19%) was transferred to ICU for shock. No risk factors for biphasic reactions could be found. Eight patients were lost to follow-up. There were no deaths during the 10-day follow-up. Biphasic anaphylactic reactions, especially clinically important ones, occurred rarely, and no mortality was found, whether the monitoring was for ≥8 h or for <8 h. Our study could motivate physicians to consider discharging patients after complete resolution of an anaphylactic reaction and to dispense with prolonged monitoring.