Intramuscular Injection Of Epinephrine Research Articles

Adrenaline intravenous therapy persistence grade I severe allergic reaction: A case report and literature review.

At present, there is still insufficient understanding of the progression from persistent allergic reactions to severe reactions. Adrenaline remains the preferred medication for severe allergic reactions, and intramuscular injection of adrenaline can also be considered for patients with grade I reactions that are difficult to alleviate gastrointestinal symptoms. It is worth further discussing whether it is possible to break the conventional intramuscular injection recommended by the guidelines when the effect of intramuscular injection is not ideal for persistent grade I severe allergic reactions. A young male, 20 years of age, was admitted to emergency department because of repeated rash for 3 days and abdominal pain for 6 hours after taking traditional Chinese medicine. After hormone therapy, the rash continued to recur and secondary gastrointestinal symptoms occurred on the 3th day. Adrenaline intramuscular injection was given to temporarily relieve the rash and abdominal pain, but symptoms still persisted. The patient was diagnosed with persistent severe allergic reaction (grade I). Continuous intravenous infusion of low-dose adrenaline under electrocardiographic monitoring, real-time monitoring of heart rate and blood pressure, and routine treatment with methylprednisolone, diphenhydramine, calcium gluconate, and cetirizine. During this period, adrenaline intramuscular injection is temporarily added when abdominal pain symptoms are obvious. The entire treatment process used a total of 6.8 mg of adrenaline. During the entire period of adrenaline intervention, the patient did not experience any new discomfort, and there were no abnormal fluctuations in heart rate, rhythm, or blood pressure. The symptoms of rash and abdominal pain gradually improved. For patients with persistent grade I severe allergic reactions, intravenous administration of low-dose adrenaline under close vital sign monitoring is safe, feasible, and highly effective in preventing biphasic, persistent, or worsening allergic reactions.

Frequencies and predictors of subcutaneous and intraosseous injection with 4 epinephrine autoinjector devices

BackgroundTo prevent anaphylaxis-associated illness, intramuscular epinephrine injection is recommended. Subcutaneous injection may reduce efficacy, and intraosseous injection promotes morbidity. A few studies suggested that commercially available thigh epinephrine autoinjectors (EAIs) may induce subcutaneous/intraosseous injection in some adults. ObjectiveTo estimate the subcutaneous/intraosseous-injection rates of 4 EAIs by comparing their needle lengths with the ultrasound-measured skin-to-muscle depth and skin-to-bone depth of the midthigh of adults with allergic diseases in a cross-sectional study and to determine patient factors that predict subcutaneous EAI injection. MethodsThigh ultrasound was conducted in a convenience-recruited cohort with minimal and maximal compression to estimate the effect of EAI-induced compression. Subcutaneous/intraosseous-injection rates were estimated for Anapen (BioProject), EpiPen (Mylan), Jext (ALK), and Emerade (Medeca). Multivariate analyses for subcutaneous-injection risk were conducted with age, male/female sex, abdominal and thigh circumferences, and upper-arm skinfold thickness. ResultsA total of 68 patients were recruited. Compression thinned the subcutaneous tissue and muscle by 1 and 9 mm, respectively, on average. Projected subcutaneous-injection rates with/without compression were high for Anapen (65%-66%), moderate for EpiPen and Jext (29%-38%), and lowest for Emerade (13%-21%). Compression introduced a small intraosseous-injection risk with Emerade (4%). Female sex predicted subcutaneous injection (odds ratio, 1.3-2.0; all P < .001). Depending on the EAI, 29% to 97% of women and 0% to 41% of men would be injected subcutaneously. Older men were at risk of intraosseous Emerade injection. Obesity-related variables predicted subcutaneous injection poorly. ConclusionAnapen was associated with high subcutaneous-injection rates. EpiPen and Jext were projected to provide intramuscular injection in all men without risk of intraosseous injection. Emerade yielded the lowest subcutaneous-injection rates in women. Compression largely affected the muscle. Trial RegistrationClinicalTrials.gov Identifier: NCT02886468

Respiratory hypersensitivity reaction related to ingestion of raspberry

A 27‐year‐old woman developed dyspnea and wheezing within 10 min after eating a piece of raspberry walnut cake, and was successfully treated with intravenous corticosteroid and intramuscular injection of adrenaline. An open oral provocation test with raspberry demonstrated immediate respiratory hypersensitivity reaction.

Current situation of anaphylaxis in Japan: Data from the anaphylaxis registry of training and teaching facilities certified by the Japanese Society of Allergology – secondary publication

BackgroundAnaphylaxis is a potentially fatal severe systemic hypersensitivity reaction that causes symptoms in multiple organs such as the skin, respiratory tract, and gastrointestinal tract; however, no nationwide epidemiological survey on anaphylaxis has been conducted in Japan. This survey aimed to elucidate the triggers and treatment of anaphylaxis in Japan. MethodsBetween February 2015 and October 2017, we prospectively collected clinical data on the triggers and treatment of patients who developed anaphylaxis or were admitted to the emergency room with anaphylaxis in the training and teaching facilities of the Japanese Society of Allergology. ResultsThis study included 79 of the 451 affiliated facilities (18%), and a total of 767 patients were enrolled; 73% of them were aged <18 years and 7% had in-hospital triggers. The most common triggers were food (68%), drugs (12%), food-dependent exercise-induced anaphylaxis (5%), insects (4%), and oral immunotherapy (3%), with drugs being the most common in-hospital trigger and food being the most common out-of-hospital trigger. Intramuscular injection of adrenaline was administered therapeutically to 38% of the patients, with 10% requiring multiple doses. Adrenaline auto-injectors were used in 12% of out-of-hospital patients. ConclusionsThe present survey revealed the most common triggers and treatments for anaphylaxis in Japan. Self-management and adrenaline administration as first-line treatment may not be done sufficiently. Therefore, it is necessary to thoroughly educate and train patients and physicians about anaphylaxis.

Pharmacokinetic and pharmacodynamic comparison of epinephrine, administered intranasally and intramuscularly: An integrated analysis

BackgroundManual intramuscular epinephrine injection is the standard of care for treating severe allergic reactions and anaphylaxis. Epinephrine autoinjectors were approved on the basis of the assumption that their pharmacokinetic and pharmacodynamic profiles are equivalent to manual intramuscular injection; however, although there is emerging evidence for product-related differences in pharmacokinetic profiles, very little is known about the comparative pharmacodynamic profiles. ObjectiveTo compare pharmacokinetic and pharmacodynamic profiles of epinephrine delivered through manual intramuscular injection, autoinjectors, and intranasal spray. MethodsThis integrated analysis was based on data from 4 randomized cross-over phase 1 trials that compared the pharmacokinetics and pharmacodynamics of epinephrine using manual intramuscular epinephrine 0.3 mg injection, epinephrine 0.3 mg autoinjectors (Symjepi and EpiPen), and epinephrine 1 mg intranasal spray (neffy). ResultsData from 175 participants showed that although neffy (1.0 mg intranasal spray) resulted in a maximum concentration (258 pg/mL) that was lower than or comparable with manual epinephrine intramuscular injection (254 pg/mL), Symjepi (438 pg/mL) and EpiPen (503 pg/mL), it led to comparable increases in systolic blood pressure (maximum effect [Emax], 16.9, 10.9, 14.9, and 18.1 mm Hg, respectively). The effect of neffy on diastolic blood pressure was also markedly more pronounced than that of other products (Emax, 9.32, 5.51, 5.78, and 5.93 mm Hg, respectively). ConclusionIntranasal delivery of epinephrine using neffy increases systolic blood pressure more efficiently than do manual intramuscular injection and epinephrine autoinjectors, despite lower maximum plasma concentrations.

A UNIQUE CASE OF ALLERGIC URTICARIA AND ANGIOEDEMA SECONDARY TO ICODEXTRIN

<h3>Introduction</h3> Icodextrin, a starch-derived glucose polymer, is an osmotic agent used to enhance peritoneal dialysis. Icodextrin has been reported to cause an exfoliative and maculopapular rash, but to our knowledge, there is no prior description of icodextrin causing urticaria or angioedema. We present a novel adverse reaction to icodextrin with findings concerning for an IgE-mediated reaction. <h3>Case Description</h3> A 43-year-old male with a history of end-stage renal disease secondary to focal segmental glomerulonephritis on peritoneal dialysis presented to the emergency department with angioedema and urticaria. He had no history of food allergy or chronic urticaria. Four days prior to his presentation, he was started on a "purple bag" dialysis solution containing icodextrin to enhance his peritoneal dialysis. Twenty-four hours after his first dialysis exchange using the "purple bag" solution, he developed diffuse urticaria that progressed to angioedema of his lips (<b>Figure 1</b>). In the emergency department, he was given an intramuscular injection of epinephrine 0.3 mg, intravenous diphenhydramine 50 mg, methylprednisolone 125 mg, and famotidine 20 mg which resulted in complete resolution of his symptoms. The "purple bag" dialysis exchanges were discontinued, and he has not had any recurrence of the urticaria and angioedema since then. <h3>Discussion</h3> Our presented patient highlighted a probable IgE-mediated allergic reaction to icodextrin or alternatively a direct mast cell degranulation secondary to the osmotic effect of icodextrin. While further investigation with skin testing can help to discern the nature of this immediate reaction, physicians should be aware of this possible reaction when prescribing icodextrin for peritoneal dialysis.

CURRENT SITUATION OF ANAPHYLAXIS IN JAPAN: DATA FROM THE ANAPHYLAXIS REGISTRY OF TRAINING AND TEACHING FACILITIES CERTIFIED BY THE JAPANESE SOCIETY OF ALLERGY

No nationwide epidemiological survey of anaphylaxis in Japan has been conducted. The aim of this study was to elucidate the triggers and treatment of anaphylaxis in Japan. We prospectively collected clinical information on the triggers and treatment of patients who developed anaphylaxis or were admitted to the emergency room with anaphylaxis in the training and teaching facilities of the Japanese Society of Allergology between February 2015 and October 2017. Seventy-nine of 451 facilities (18%) participated in the study, and a total of 767 patients (under 18 years, 73%; in-hospital, 7%) were enrolled. The most common triggers were food (68%), drugs (12%), food-dependent exercise-induced anaphylaxis (5%), insects (4%), and oral immunotherapy (3%), with drugs being the most common in-hospital trigger and food being the most common out-of-hospital trigger. The intramuscular injection of adrenaline in medical institutions accounted for 38% of cases, 10% of which required multiple doses. The rate of use of adrenaline self-injections in out-of-hospital cases was 12%. The present study revealed the most common triggers and treatment for anaphylaxis in Japan. Self-management at the onset of anaphylaxis and adrenaline administration as the initial treatment may be insufficient. Therefore, it is necessary to thoroughly instruct patients and educate physicians regarding anaphylaxis.

Comparison of the efficacy of continuous intravenous infusion versus intramuscular injection of epinephrine for initial anaphylaxis treatment.

AimContinuous intravenous (CIV) infusion of epinephrine for the treatment of anaphylaxis may be required if symptoms do not improve after intramuscular (IM) injection. As CIV infusion permits precise dose adjustment, we compared treatment course and adverse events following CIV infusion and IM injection of epinephrine for the management of anaphylaxis.MethodsMedical records of patients, who were treated for anaphylaxis with epinephrine, were 18 years or older, and were admitted to our department from April 2005 to March 2016, were retrospectively reviewed. The cases were categorized as CIV infusion or IM injection, and treatment course and outcomes were compared between the two groups.ResultsOf the 142 eligible cases, there were 78 in the CIV infusion group and 64 in the IM injection group. The CIV infusion group had lower systolic blood pressure, more respiratory symptoms, and higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, but required a lower total dose of epinephrine, had fewer adverse events after epinephrine administration, and showed lower incidence of biphasic reactions. In addition, compared with the IM injection group, time to administration of epinephrine was significantly longer (P < 0.001), but time to resolution of symptoms, both from contact and epinephrine administration, was significantly shorter (P < 0.01 and P = 0.03, respectively).ConclusionContinuous intravenous infusion of epinephrine for the treatment of anaphylaxis may be safe, has fewer adverse events, improves symptoms, and is relatively easy to administer under ready conditions. CIV infusion of epinephrine may also reduce the incidence of biphasic reactions.

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Anaphylactic Reaction to Dulaglutide: A Glucagon Like Peptide- 1 Receptor Agonist

Introduction: The development of Glucagon like peptide-1 (GLP-1) receptors agonists represents an important advancement in the management of type 2 diabetes. The long-acting GLP-1 receptor agonists improve glycemic control, promote weight loss. Anaphylaxis to GLP-1 receptor agonists and mainly Dulaglutide is a rare but serious side effect. We report a patient with Type 2 DM who was recently started on Dulaglutide and started to experience systemic hypersensitivity reactions that required discontinuing the medication and inpatient hospitalization. Case: A 53-Year-old Caucasian female with past medical history of type 2 DM on Metformin presented to the ED with sudden onset of sporadic itchy rash on the lip and chin associated with lip swelling within one hour of her first injection of Dulaglutide. She denied difficulty breathing, rash or pruritus on any other part of the body. She denied any food allergies. The patient used two tablets of Oral Diphenhydramine 25 mg with minimal improvement in her symptoms which warrant her to come to the ED. On arrival, she was Afebrile with a HR 97 beats/minute, a BP of 105/58 mm of Hg and a RR of 17 breaths/minute. The rash was blotchy, non- tender, more evident on the upper lip as compared to the lower lip. Lab results showed WBC count of 11 k/uL with basophils of 2% and HbA1c 8.6%. She was treated for her allergic reaction with Intramuscular injection of Epinephrine 0.3mg, Intravenous Dexamethasone 6mg and Intravenous Diphenhydramine 25mg. She was then transferred to the observation unit for monitoring. Her home metformin 500mg two times a day was continued. After 48 hours, the patient’s symptoms were improved and she was discharged home. She was advised to follow up with her PCP and endocrinologist and stop Dulaglutide. Discussion: GLP-1 receptor agonists are commonly used currently in the management of DM due to their beneficial effect in controlling blood glucose as compared to other diabetic medications. Rarely, a potentially life-threatening reaction, such as anaphylactic reactions have been documented with GLP-1 receptor agonist. Systemic allergic reaction to GLP-1 Agonist Exenatide has been reported in the literature. Our patient had anaphylactic reaction after using Dulaglutide. The mechanism of action of anaphylaxis in GLP-1 receptor agonists is thought to be related to IgE mediated and the immune response was demonstrated by basophil activation.

Allergic Reactions Including Anaphylaxis After Receipt of the First Dose of Pfizer-BioNTech COVID-19 Vaccine - United States, December 14-23, 2020.

As of January 3, 2021, a total of 20,346,372 cases of coronavirus disease 2019 (COVID-19) and 349,246 associated deaths have been reported in the United States. Long-term sequalae of COVID-19 over the course of a lifetime currently are unknown; however, persistent symptoms and serious complications are being reported among COVID-19 survivors, including persons who initially experience a mild acute illness.* On December 11, 2020, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for Pfizer-BioNTech COVID-19 vaccine to prevent COVID-19, administered as 2 doses separated by 21 days. On December 12, 2020, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for use of Pfizer-BioNTech COVID-19 vaccine (1); initial doses were recommended for health care personnel and long-term care facility residents (2). As of December 23, 2020, a reported 1,893,360 first doses of Pfizer-BioNTech COVID-19 vaccine had been administered in the United States, and reports of 4,393 (0.2%) adverse events after receipt of Pfizer BioNTech COVID-19 vaccine had been submitted to the Vaccine Adverse Event Reporting System (VAERS). Among these, 175 case reports were identified for further review as possible cases of severe allergic reaction, including anaphylaxis. Anaphylaxis is a life-threatening allergic reaction that does occur rarely after vaccination, with onset typically within minutes to hours (3). Twenty-one cases were determined to be anaphylaxis (a rate of 11.1 per million doses administered), including 17 in persons with a documented history of allergies or allergic reactions, seven of whom had a history of anaphylaxis. The median interval from vaccine receipt to symptom onset was 13 minutes (range=2-150 minutes). Among 20 persons with follow-up information available, all had recovered or been discharged home. Of the remaining case reports that were determined not to be anaphylaxis, 86 were judged to be nonanaphylaxis allergic reactions, and 61 were considered nonallergic adverse events. Seven case reports were still under investigation. This report summarizes the clinical and epidemiologic characteristics of case reports of allergic reactions, including anaphylaxis and nonanaphylaxis allergic reactions, after receipt of the first dose of Pfizer-BioNTech COVID-19 vaccine during December 14-23, 2020, in the United States. CDC has issued updated interim clinical considerations for use of mRNA COVID-19 vaccines currently authorized in the United States (4) and interim considerations for preparing for the potential management of anaphylaxis (5). In addition to screening for contraindications and precautions before administering COVID-19 vaccines, vaccine locations should have the necessary supplies available to manage anaphylaxis, should implement postvaccination observation periods, and should immediately treat persons experiencing anaphylaxis signs and symptoms with intramuscular injection of epinephrine (4,5).

Management of anaphylaxis in the dental practice: an update.

Anaphylaxis is a severe and potentially life-threatening allergic reaction that can occur in the dental practice. There are a number of dental-related causes including mouthwashes, local anaesthetics, latex and antibiotics. The dental team must be able to respond effectively and manage the life-threatening situation appropriately following Resuscitation Council UK guidelines. The timely administration of adrenaline is life-saving; any delays can lead to a poor outcome. With the current national supply issues with adrenaline auto-injector devices, there is an expectation that GDPs should be competent at drawing up adrenaline from an ampoule and administrating it intramuscularly. The aim of this article is to provide an update on the management of anaphylaxis in the dental practice with particular reference to the procedure for intramuscular injection of adrenaline.

A single centre retrospective study of systemic reactions to subcutaneous immunotherapy

BackgroundSubcutaneous immunotherapy (SCIT) is the standard approach for treating patients with sensitizations to aeroallergens. However, immunotherapy can trigger severe systemic reactions if delivered inappropriately or to high risk patients. We sought to characterize and quantify SCIT systemic reactions requiring epinephrine administration during a 6-year period in a Canadian setting following the recommendations for components and dosages published in the 2010 Canadian Society of Allergy and Clinical Immunology (CSACI) Immunotherapy Manual.MethodsA single centre retrospective chart review was performed for all patients with systemic reactions to subcutaneous immunotherapy requiring intramuscular epinephrine injection between January 2011 and October 2017. Each systemic reaction requiring epinephrine was reviewed for baseline patient characteristics, details of the reaction, and reaction severity. Research ethics approval was obtained through McMaster University.Results28 of 380 patients experienced a systemic reaction requiring epinephrine administration, with an incidence rate of 1 per 1,047 injection visits (0.095%). 26 of the 28 reactions occurred within the mandatory 30-minute observation period post allergen immunotherapy. Of the 28 patients that experienced a systemic reaction to SCIT, 11 patients had asthma and 5 patients had a history of possible food allergy. All of the systemic reactions occurred during injections from vial number 4, and five patients reacted to their first shot of a re-ordered extract. 10 of the 28 patients required more than one intramuscular injection of epinephrine, and 20 of 28 patients were transferred to the hospital by ambulance.ConclusionsThis is the first Canadian study to review patients with systemic reactions to subcutaneous immunotherapy. Several best practice methods were employed throughout the study to optimize subcutaneous delivery of immunotherapy extract, and our recorded per injection incidence rate for systemic reactions was comparable or below the rate published in similar studies. The recommendations in the CSACI Immunotherapy Manual provide an approach to standardizing prescriptions for SCIT to maximize immunotherapy efficacy and reduce the risk of systemic reactions, though similar studies in larger multicenter settings are needed to confirm these observations. These observations provide important objective information to clinicians about the potential risks for systemic reactions in patients considering SCIT.

Guía de Actuación en Anafilaxia en Latinoamérica. Galaxia-Latam

Anaphylaxis is a severe allergic reaction with a rapid onset and it is potentially life-threatening. Its clinical manifestations are varied; they may affect the skin, the cardiovascular system, the respiratory system, and the digestive system, among others. The treatment of choice, which is an intra-muscular injection of epinephrine (adrenaline), must be applied promptly. Therefore, being prepared to recognize it properly is of crucial importance. The objective of this clinical practice guide is to improve the knowledge of health professionals about anaphylaxis and, consequently, to optimize the treatment and long-term management of this reaction. This guide is adapted to the peculiarities of Latin America; especially in matters regarding the treatment. The need to introduce epinephrine auto-injectors in countries that don't have them yet is highlighted.

Non-Auto-Injector Epinephrine Administration by Basic Life Support Providers: A Literature Review and Consensus Process

Anaphylaxis is a life-threatening condition with a known effective prehospital intervention: parenteral epinephrine. The National Association of EMS Physicians (NAEMSP) advocates for emergency medical services (EMS) providers to be allowed to carry and administer epinephrine. Some states constrain epinephrine administration by basic life support (BLS) providers to administration using epinephrine auto-injectors (EAIs), but the cost and supply of EAIs limits the ability of some EMS agencies to provide epinephrine for anaphylaxis. This literature review and consensus report describes the extant literature and the practical and policy issues related to non-EAI administration of epinephrine for anaphylaxis, and serves as a supplementary resource document for the revised NAEMSP position statement on the use of epinephrine in the out-of-hospital treatment of anaphylaxis, complementing (but not replacing) prior resource documents. The report concludes that there is some evidence that intramuscular injection of epinephrine drawn up from a vial or ampule by appropriately trained EMS providers—without limitation to specific certification levels—is safe, facilitates timely treatment of patients, and reduces costs.

Basic Life Support Access to Injectable Epinephrine across the United States

Background: Aggressive epinephrine administration has growing support in the treatment of anaphylaxis, a life-threatening allergic reaction. Emergency Medical Services (EMS) providers are frequently in a position to provide the first care to someone experiencing an anaphylactic reaction. Intramuscular injection of epinephrine is the definitive pharmacologic treatment for many associated symptoms. While easy to use, epinephrine autoinjectors (EAI) are prohibitively expensive, having increased in price ten-fold in ten years. Some states and EMS departments have begun expanding the scope of practice to allow Basic Life Support (BLS) providers, previously restricted to noninvasive therapies, to administer epinephrine by syringe. Objectives: To compile a current and comprehensive list of how epinephrine is carried and used by EMS across the USA. Methods: An online survey focusing on anaphylaxis protocols and epinephrine administration was sent to state EMS medical directors and officials in all 50 states. Follow-up telephone calls were made to ensure compliance. Data were analyzed with descriptive statistics. Results: Forty-nine of the 50 states in the USA provided a survey response. Texas responded but declined to participate in the survey because of practice variability across the state. In the other states, the form of epinephrine allowed or required on BLS ambulances was consistent with the scope of practice of their Basic Emergency Medical Technician (EMT). Thirteen states had training programs to allow BLS providers to inject epinephrine; 7 were considering it; 29 were not. Twenty-seven states specified EAI as the only form of epinephrine required or allowed on their BLS ambulances. No states reported allowing any level of EMS provider below EMT to use alternatives to EAI. Conclusion: This study confirms that many states have expanded the training of BLS providers to include the use of syringe injectable epinephrine. Even so, the majority of states relied on EAI in BLS ambulances.

SIX CASES OF WHEAT-DEPENDENT EXERCISE-INDUCED ANAPHYLAXIS IN CHILDREN

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is often reported in adults for whom the specific IgE to ω-5 gliadin can be a useful diagnostic test. However, few cases of WDEIA in children have been reported. We herein report six cases (aged 7-16 years) of children with WDEIA, who had no clinical history of immediate-type wheat allergy but who were diagnosed by a wheat ingestion + exercise provocation test. The specific IgE to wheat ranged <0.35-3.49 (median 1.64) UA/ml. Skin prick tests using wheat extract were performed on 3 patients who showed either a negative or low specific IgE titer to wheat, and all of them resulted in negative findings. The specific IgE to ω-5 gliadin was below the detection limit in all cases. Aspirin-supplemented provocation tests were performed to 4 cases who had negative results in the wheat + exercise test. All of these resulted in a positive reaction, and two of them provoked the occurrence of anaphylactic shock, which was relieved by the intramuscular injection of adrenaline. WDEIA in children cannot be ruled out by serological tests alone. On the other hand, severe symptoms might be provoked by the provocation test. Therefore, a safe procedure is warranted for the diagnosis of WDEIA in children.

Asthme et allergie alimentaire

In children early diagnosis of food allergy associated with asthma is very important because of less effective control and the risk of severe anaphylaxis or an acute asthma exacerbation. Asthma and food allergy are often associated with skin disorders such as eczema, frequently in the clinical picture of the dermato-respiratory syndrome associated with a mutation of filaggrin. A very precise inquiry is essential to detect food intolerance. The diagnosis is then confirmed by skin tests, specific IgE measurement and finally an oral challenge near an intensive care unit. An asthma exacerbation after eating an allergenic food is a true anaphylactic reaction and does not respond well to the usual treatment with beta 2 agonists. It needs urgent intramuscular injection of epinephrine. An asthma action plan and an emergency kit with epinephrine is essential as soon as the diagnosis is confirmed. Education of the child and family is also important. Anti-IgE therapy by Omalizumab is recommended for severe asthma resistant to standard treatment but has not been tested in food allergy and, at this stage, is not indicated.

Adherence to the Treatment Choices of Anaphylaxis: An Epidemiological View of the Pediatric Patients

Anaphylaxis is a life threatening condition.There is a concensus that the rapid intramuscular injection of adrenaline is life-saving and first line intervention.We aimed to describe adherence to the treatment choices of anaphylaxis besides the epidemiological characteristics. This retrospective study included the children with available records referred to the outpatient clinics of Pediatric Allergy and Immunology Department of the Karadeniz Technical University from October 2002 to April 2014 for investigation of anaphylaxis. One hundred and forty-five episodes of anaphylaxis were reported in 65 children(45 boys, p<0.05).The median age was 8 years(range: 1.5 months–17 years).The causative agents were foods in 67 (46.2%) episodes,hymenoptera venom in 33 (22.8%),drugs&medications in 19(13.1%).In twenty-six episodes(17.9%),the causative agent was unidentified referred as idiopathic.When compared according to age groups,the rate of food anaphylaxis was significantly high in the 0–2 years age group(n = 22, 88% P <0.01, OR: 0.079, 95% CI: 0.02–0.27),while hymenoptera venom anaphylaxis was high in the 7–11 age group(n = 20, 48.8%, P < 0.01, OR: 0.15, 95% CI: 0.06–0.34).The patients with 123(84.8%) episodes received antihistamines,the patients with 97(66.9%) received corticosteroids, the patients with 21(14.5%) episodes received adrenaline, and the patients with 21(14.5% for 132 episodes) episodes received beta-2-agonists prior to admission to our clinics. The use of adrenaline as a first line intervention of the treatment of anaphylaxis is not often applied.This seems due to the various barriers related to clinicians,patients and regulators.It is necessary to overcome those barriers in order to settle and improve emergency management of anaphylaxis.

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.