Intravenous Diphenhydramine Research Articles

A CASE OF RECURRENT HIVES WITH LACTATION

<h3>Introduction</h3> Development of hives due to lactation is a rare phenomenon seen in the postpartum period. Lactation is influenced by oxytocin and prolactin release, which stimulates lactogenesis, and initiates milk secretion. We describe a rare case of postpartum hives that improved with the use of bromocriptine. <h3>Case</h3> A 33-year-old female presented to clinic with recurrent hives postpartum. Three years prior to presentation she delivered her first child via scheduled cesarean section. After four days of colostrum feeding, she began breastfeeding, but developed diffuse hives within 20 minutes. Although initially resolving with diphenyhradmine, she had recurrent flare of hives every 2-3 hours, resulting in two hospitalizations and intravenous diphenhydramine for persistent hives. Her hives disappeared on postpartum day nine. She delivered her second child via caesarean section. She developed severe, diffuse hives on the fourth day of hospitalization at the time of lactogenesis, refractory to intravenous diphenhydramine, H2-antagonists and methylprednisolone. She was started on bromocriptine with improvement in her hives within hours of administration. <h3>Discussion</h3> Hives with breastfeeding represents a unique phenomenon that can be debilitating postpartum. There are few case reports detailing lactation anaphylaxis, an IgE-independent reaction related to a prolactin surge at time of let-down. Similarly, our patient presents with two recurrent episodes of hives at the time of lactation initiation. This theory is supported by her rapid improvement with administration of bromocriptine, a dopamine antagonist that suppresses prolactin secretion. Early recognition of prolactin-induced hives could allow for intervention prior to delivery with antihistamines, glucocorticoids, and bromocriptine to provide future guidance with subsequent deliveries.

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.

Midwifery Management of a Birthing Person with Cervical Edema During Labor.

During active labor, a birthing person with cervical edema often has a dysfunctional or prolonged labor and, therefore, an increased risk for cesarean birth. Midwives seeking evidence on how to manage cervical edema when they are faced with this clinical situation will note a gap in the literature regarding the management of cervical edema that this report aims to fill. This case will discuss the use of intravenous diphenhydramine (Benadryl), the application of ice to the cervix, side-lying release, epidural analgesia use, manual reduction of the cervix, and various positions to encourage reduction in cervical swelling. It is hoped these strategies will add to a midwife's clinical resources by providing ways to promote vaginal birth in the setting of cervical edema during labor.

Use of Diphenhydramine for Pain Management in the Emergency Department: A Systematic Review and Meta-analysis

BACKGROUND Diphenhydramine, commonly prescribed as an antihistamine drug, is not known for its analgesic effect and its use in acute pain management has not been thoroughly investigated. AIM In this study, we aim to explore the analgesic properties of diphenhydramine and its role in acute pain reduction in the emergency department (ED). METHODS A systematic review and meta-analysis were performed. The inclusion criteria were randomised controlled trials that investigated the effect of intravenous diphenhydramine on the management of acute pain. Acute pain reduction was defined as a reduction in the visual pain score within one hour of drug administration. We excluded non-English articles, articles that measured the impact of diphenhydramine beyond the acute period, and those that used a pain score other than the 10-point visual pain scale. The information sources included PubMed, Google Scholar, Cochrane, PROSPERO, and grey literature (ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform) databases for articles published between 1963 and January 2022, along with the articles referenced at the end of the reviews, for the keywords ‘diphenhydramine’, ‘antihistamine’, ‘pain’, and ‘analgesia’. The researchers used the RoB 2 Cochrane risk-of-bias tools for randomised controlled trials. RESULTS We included four studies out of 128,902 involving 438 patients, out of whom 218 received diphenhydramine for pain control. The mean pain score in patients who received diphenhydramine was reduced by 28%; t(6)= -2.879, 95% CI [-2.87 to -0.23], p=0.028. When the baseline pain score was included in the analysis, we noted a reduction of 48% from the initial pain score. The pooled effect size or mean difference in acute pain reduction favouring diphenhydramine, taken from a random-effects model, was -1.53 (95% CI: [-2.35 to -0.70]) using Cohen’s d. CONCLUSION This meta-analysis confirms the analgesic advantages of diphenhydramine and supports its consideration as an adjunct for acute pain management in the ED.

A randomized double-blind feasibility study comparing cetirizine and diphenhydramine in the prevention of paclitaxel-associated infusion-related reactions: the PREMED-F1 study

PurposeCetirizine is a less sedative alternative to diphenhydramine for the prevention of infusion-related reactions (IRR) to paclitaxel. However, its use remains controversial. In this study, we assessed feasibility for a future definitive non-inferiority trial comparing cetirizine to diphenhydramine as premedication to prevent paclitaxel-related IRR.MethodsThis was a single-center randomized prospective feasibility study. Participants were paclitaxel-naive cancer patients scheduled to start paclitaxel chemotherapy. They were randomly assigned to receive either intravenous diphenhydramine 50 mg + oral placebo (control) or intravenous placebo + oral cetirizine 10 mg (intervention) for their first two paclitaxel treatments. The percentage of eligible patients completing a first paclitaxel treatment and the recruitment rate were assessed (feasibility outcomes). Drowsiness was measured at baseline and at selected time points using the Stanford Sleepiness Scale (SSS) (safety outcome). IRR events were also documented (efficacy outcome).ResultsAmong 37 eligible patients, 27 were recruited and randomized (control 13; intervention 14) and 25 completed the study. The recruitment rate was 4.8 participants/month, meeting the primary feasibility target. Drowsiness was the main adverse effect associated with the premedication. The increase in drowsiness compared to baseline (ΔSSS) was greater in the diphenhydramine group compared to the cetirizine group (median ΔSSS 2 (IQR 3.25) vs median ΔSSS 0 (IQR 1), p < 0.01) when measured one hour after the premedication administration. One participant had an IRR and no unexpected serious adverse event occurred.ConclusionThe trial methods were feasible in terms of recruitment, retention, and safety. Cetirizine was significantly less sedating than diphenhydramine. IRR were infrequent and a larger trial is warranted to confirm non-inferiority for IRR prevention.Trial registrationClinicalTrials.gov, NCT04237090 (22.01.2020).Supplementary InformationThe online version contains supplementary material available at 10.1007/s00520-021-06734-4.

The Effect of Intraoperative Diphenhydramine/Morphine on Acute Pain and Opioid Consumption after Spine Surgery

Background: One of the most common problems after spine surgery is very severe pain that usually affects outcome of patients after surgery and duration of hospital stay. Acute postoperative pain has several mechanisms, and multimodal analgesia by different mechanism of action will help control to it. In this study, we intended to investigate the effect of intravenous diphenhydramine injection during induction of anesthesia and morphine before incision on the control of acute pain in postoperative laminectomy. Methods: 130 patients scheduled for spine surgeries were assigned to receive a single pre induction dose of diphenhydramine 0.4mg/kg IV (D group) and morphine 0.15mg/kg before incision in addition acetaminophen 1gr IV at the end of surgery and just morphine 0.15mg/kg and acetaminophen 1gr IV (C group) in a randomized, double-blind trial. Postoperative pain, analgesic requirements in recovery and 24 hr after surgery were assessed. Results: The mean pain intensity in recovery was lower in the diphenhydramine group than in the control group (MD, 2.13; 95% confidence interval (CI), 1.72–2.53; P &lt; .0001) and the need for analgesia was much lower in the diphenhydramine group than in the control group. P &lt; 0.001. The severity of pain and the need for analgesics in the diphenhydramine group had a significant decrease in the ward compared to the control group. Conclusion: Prophylactic diphenhydramine 0.4 mg/kg at induction of general anesthesia in combination with morphine 0.15mg/kg before incision and acetaminophen 1gr at the end of surgery reduced the postoperative severity of acute pain and opioids requirement in the early postoperative period after spine surgeries.

Pharmacokinetics of diphenhydramine following single-dose intravenous and oral administration in non-fasted adult horses.

Diphenhydramine is an H1 receptor antagonist used to control urticaria and other allergic signs caused by type I hypersensitivity reactions in horses (Equus caballus). Limited studies have been conducted on pharmacokinetics of this drug in horses, with no studies involving oral formulations. Our study investigated pharmacokinetics of an oral diphenhydramine formulation compared to intravenous administration in non-fasted adult horses. Six healthy horses underwent a single administration of three different doses of diphenhydramine (1mg/kg intravenously, 1mg/kg intragastrically, and 5mg/kg intragastrically) with a two-week washout period between doses. Bioavailability of intragastric diphenhydramine was less than one percent and six percent for 1mg/kg and 5mg/kg intragastric doses, respectively. This poor bioavailability is similar to what is reported in dogs. Two of six horses experienced transient side effects after intravenous diphenhydramine administration, emphasizing the need for determining therapeutic plasma levels in efforts to determine the lowest effective dose minimizing risk of adverse effects. The main conclusion of our study was that oral diphenhydramine at doses up to 5mg/kg are unlikely to achieve therapeutic plasma levels in adult horses.

DRESS syndrome in the setting of oxacillin therapy\u2014a call for better patient preparedness: a case report

BackgroundDrug reaction with eosinophilia and systemic symptoms syndrome is a rare but severe and potentially life-threatening hypersensitivity reaction, with significant morbidity and mortality. The clinical presentation of drug reaction with eosinophilia and systemic symptoms may include extensive skin rash, fever, lymphadenopathy, internal organ involvement, eosinophilia, and atypical lymphocytosis, most commonly due to drug-induced reaction. Our case is a rare occurrence of drug reaction with eosinophilia and systemic symptoms syndrome in the setting of oxacillin therapy.Case presentationA 55-year-old Caucasian male presented to the emergency department on account of acute onset, 2-day history of generalized pruritic rash with associated fever, occurring 3 weeks after commencing therapy with intravenous oxacillin for methicillin-sensitive Staphylococcus aureus bacteremia. He had no known drug allergies. Two days prior to hospitalization, he had a telehealth visit with the infectious diseases specialist on account of his rash, and was recommended to use oral diphenhydramine. However, with the onset of fever and persistence of his rash, he was advised to discontinue the oxacillin and present to the emergency department. On examination, he was febrile at 101.2 °F and had a generalized blanchable maculopapular and morbilliform rash involving the face, trunk, upper and lower extremities, but sparing the palms, soles, and oral mucosa. He had palpable nontender lymph nodes in the cervical and inguinal regions bilaterally. Laboratory studies revealed atypical lymphocytosis, eosinophilia, neutrophilia, and elevated serum transaminases. He was started on intravenous diphenhydramine and admitted to the in-patient medical service. On the second day of hospitalization, his fever resolved. However, his rash was persistent and generalized, as well as elevated transaminases and an abnormal cell count on the second day of hospitalization. To complete his 6-week course of antibiotics for methicillin-sensitive Staphylococcus aureus bacteremia, he was switched to an alternative therapy with cefazolin, and he was scheduled for weekly follow-up assessments following hospital discharge.ConclusionsHealthcare providers should increasingly be aware of the significant morbidity and mortality attributable to drug reaction with eosinophilia and systemic symptoms syndrome and the potential medications which may incite such life-threatening reactions. Early recognition of drug reaction with eosinophilia and systemic symptoms syndrome and prompt institution of management strategies can promote improved clinical outcomes. Enhanced patient–provider communication strategies should be implemented to better prepare patients for the likelihood of such drug reactions, with the goal of improving patient-centered care and adherence with treatment strategies.

Hereditary angioedema

A 14-year-old African American female presented to the emergency department with spontaneous, sudden-onset lip swelling for 1 h. On examination, there was significant water-bag edema of the upper lip extending to the philtrum and premaxilla. Nasopharyngeal laryngoscopy revealed a patent airway without edema. She was initiated on intravenous dexamethasone, famotidine, and diphenhydramine, after which her edema improved but did not resolve. She was subsequently transferred to a local pediatric hospital and upon further testing she was found to have a C1 esterase inhibitor de novo gene mutation. Angioedema causes localized, non-pitting edema of the dermis, subcutaneous and submucosal tissue, and often manifests in the lips, face, mouth, and throat. Signs of laryngeal involvement include change in voice, stridor, dysphagia, and dyspnea. When laryngeal edema is present, it may necessitate definitive airway management and patients should be monitored in the intensive care unit.

A randomized double-blind pilot study comparing cetirizine with diphenhydramine in the prevention of paclitaxel-associated infusion-related reactions.

e24080 Background: Cetirizine is a less sedative alternative to diphenhydramine for the prevention of infusion-related reactions (IRR) to paclitaxel. However, there is no prospective data to support its use in this context. In this study, we conducted a feasibility study for a future definitive non-inferiority trial comparing cetirizine with diphenhydramine as premedication to prevent paclitaxel-related IRR. Methods: This was a single center randomized double-blind parallel-group prospective pilot study. Participants were paclitaxel-naive cancer patients scheduled to start paclitaxel chemotherapy, alone or in combination. They were assigned to receive either intravenous diphenhydramine 50 mg + oral placebo (diphenhydramine group) or intravenous placebo + oral cetirizine 10 mg (cetirizine group) for their first two paclitaxel treatments. To assess the feasibility of a larger study, the percentage of eligible patients completing a first paclitaxel treatment and the recruitment rate were calculated. IRR events were documented. Change in drowsiness compared with baseline was assessed using the Stanford Sleepiness Scale (SSS). Results: Among 37 eligible patients, 27 were recruited and randomized (control 13; intervention 14) and 25 completed the study. The recruitment rate was 4.8 participants/month, meeting the primary feasibility target of 4 participants per month. One participant had an IRR (cetirizine group, CTCAE grade 2) and no unexpected serious adverse events occurred. Drowsiness was the main adverse effect associated with the premedication. The increase in drowsiness compared to baseline (ΔSSS) was greater in the diphenhydramine group compared to the cetirizine group (median ΔSSS 2 (IQR 3.25) vs median ΔSSS 0 (IQR 1), p &lt; 0.01) when measured one hour after the administration of the premedication. Patient self-assessed moderate or intense discomfort caused by drowsiness was exclusively reported in the diphenhydramine group, by 4 out of 13 participants. Conclusions: The trial methods were feasible in terms of recruitment rate, retention and patient safety. IRR were infrequent and a larger trial is warranted to confirm non-inferiority for IRR prevention. Cetirizine was significantly less sedating than diphenhydramine when administered as premedication to prevent paclitaxel-associated IRR. Clinical trial information: NCT04237090. [Table: see text]

Treating Acute Posttraumatic Headache

Intravenous metoclopramide plus diphenhydramine is effective in treating primary headaches. To test this treatment's efficacy for posttraumatic

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.

Effectiveness of Standard Combination Therapy in Pediatric Migraine

BackgroundA combination of parenteral medications (often referred to as standard combination therapy) is frequently used in the treatment of acute migraine in the pediatric emergency department (PED). The primary aim of this study was to evaluate the two-hour, 24-hour, and seven-day impact of one such regimen on pain in children who present to the PED. Standard combination therapy for purposes of our study is defined as a bolus of intravenous saline, and a combination of intravenous ketorolac, prochlorperazine, and diphenhydramine. MethodsThis prospective observational study included 120 children between the ages seven and 18 years who presented to the PED with migraine, whose parents could read and understand the consent form in English, and who were treated with standard combination therapy. The primary outcome measure for this study was the change in severity of pain as noted by the child using the Faces Pain Scale-Revised. We analyzed normally distributed continuous variables by mean and standard deviation, whereas non-normally distributed continuous variables are reported by median and interquartile range. ResultsNonparametric Friedman testing on the entire cohort (n = 120) noted that there was a statistically significant change in the Faces pain scale from before administration of standard combination therapy to the two-hour, 24-hour, and one-week time point with a reduction in pain score of 87.5%, 100%, and 50%, respectively, at the three time points. ConclusionsThis study noted moderate relief of pain after administration of standard combination therapy, which persisted at one-week after administration.

Intravenous Cetirizine for Acute Urticaria

Intravenous (IV) diphenhydramine has long been a staple for treating patients with acute urticaria in urgent care settings, but it causes substantial

ALLERGIC ACUTE CORONARY SYNDROME

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Kounis syndrome describes a unique phenomenon of acute coronary syndrome (ACS) in the presence of allergic or anaphylactic reactions. This syndrome is caused by inflammatory mediators - histamine being the most prominent - inducing coronary artery vasospasm. We present a case of allergic ACS in a patient with mast cell activation syndrome (MCAS). CASE PRESENTATION: A 35-year-old woman with a history of MCAS, chronic urticaria, migraines, severe persistent asthma, and recent DVT on therapeutic enoxaparin, was hospitalized for pain and edema concerning for an acute flare of MCAS. She was treated with oral steroids and a continuous intravenous diphenhydramine infusion. The patient later developed sepsis secondary to a staphylococcus aureus line infection and was started on cefazolin. Overnight, she developed asymptomatic diffuse ST elevations in addition to tachycardia with a rate in the 140s (baseline heart rate 100-130) and was found to have elevated troponins. Her initial troponin measurement was 0.28 and declined to 0.26 and 0.21. On physical exam she had scattered urticaria, tachycardia, normal heart sounds without a pericardial friction rub and was saturating well on room air. She was continued on steroids and diphenhydramine infusion with the addition of famotidine. She had no previous cardiac history and no significant family history of cardiovascular disease. TEE done 6 months prior was negative for mural thrombus and showed normal EF; echo the day after the onset of ST elevations showed no significant findings. DISCUSSION: Histamine induced coronary vasospasm may mimic classic ACS in patients undergoing an allergic reaction. Kounis syndrome is suspected to be largely underdiagnosed and should be considered in patients with anaphylactic or other allergic responses. Our patient likely had histamine-mediated ACS after initiation of cefazolin. Her troponin plateau makes ST-elevation myocardial infarction less likely. Other differentials to consider include myopericarditis given the diffuse ST elevations, however, given the onset in close proximity to new antibiotic initiation, her history is suspicious for an allergy mediated process. Furthermore, Kounis syndrome is more commonly found in individuals with other vasospastic conditions such as migraine. Treatment for allergic ACS includes management of underlying allergic response with corticosteroids and antihistamines; calcium channel blockers can also be considered. ACS protocol can be implemented in patients with underlying cardiac disease, but caution should be used with beta-blockers to avoid exacerbation of vasospasm. CONCLUSIONS: Patients undergoing an allergic reaction may experience classic signs and symptoms of ACS induced by histamine-mediated coronary vasospasm. Kounis syndrome is an important differential to consider in any allergy patient with new-onset ST changes or transient angina with or without concomitant urticaria. Reference #1: Kounis NG. Kounis syndrome: an update no epidemiology, pathogenesis, diagnosis and therapeutic management. CCLM. 2016; 54(10):1545–1559 Reference #2: Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: the concept of allergic angina. Br J Clin Pract. 1991;45(2):121-128. Reference #3: Kounis NG. Kounis syndrome: an update on epidemiology, pathogenesis, diagnosis and therapeutic management. Clin Chem Lab Med. 2016;54(10):1545-1559. doi:10.1515/cclm-2016-0010 DISCLOSURES: No relevant relationships by Jennifer Cortes, source=Web Response No relevant relationships by Kelly Roth, source=Web Response

DIPHENHYDRAMINE AS ADJUNCTIVE THERAPY DURING MODERATE SEDATION FOR ENDOBRONCHIAL ULTRASOUND

SESSION TITLE: Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Endobronchial ultrasound (EBUS) and real-time guidance of transbronchial needle aspiration (TBNA) has become a widely adopted tool in evaluation of intrathoracic lymphadenopathy for malignant or non-malignant disease. EBUS has been shown to have comparable diagnostic yield and safety profile when done with either moderate sedation (MS) or deep sedation (DS). The purpose of this study was to assess the use of diphenhydramine in bronchoscopies and specifically EBUS/TBNA. METHODS: Patient data was collected via chart review of all bronchoscopies done at the Kansas City VA Medical Center between July 2018 and June 2019. Only procedures done under MS were included. Sedation medications used were fentanyl and midazolam. The use of intravenous diphenhydramine, dose and timing was at the discretion of the proceduralist. RESULTS: A total of 165 bronchoscopies were performed under MS; 84 were EBUS procedures. Of the EBUS patients, 81 (96.4%) patients were male; mean age was 66.4±10.7. No patients had a documented history of chronic opioid use.Midazolam and fentanyl were used for induction and maintenance of sedation in all EBUS patients. The mean doses were 5.3±3.3 mg of midazolam and 203.9±52.1 mcg of fentanyl. Diphenhydramine was used in 62 (73.8%) of EBUS procedures. Twenty (32.3%) patients received diphenhydramine at induction compared to 42 (67.7%) who only received it during the procedure. The mean dose of diphenhydramine was 41.5±12.7 mg.Comparing EBUS in which any diphenhydramine was used to cases in which it was not, there was no significant difference in the cumulative doses of midazolam (5.6±3.5 vs. 4.5±2.5mg, p=0.161) and fentanyl (204.8±57.6 vs. 201.1±33.2mcg, p= 0.777). The time to adequate sedation was significantly higher in patients who received diphenhydramine (11.1±4.9 vs. 8.6±2.9 min, p=0.006). Procedure time (64.0±25.1 vs 61.4±20.2 min, p=0.660) and recovery time (81.4±32.4 vs. 81.3±47.9 min, p=0.995) were not significantly different.Compared to no use at all, any diphenhydramine use (at induction or during the procedure) was associated with a lower fentanyl dose per minute (4.2±2.6 vs. 7.2±5.0 mcg/min, p<0.001) and a trend towards a lower midazolam dose per minute although not statistically significant (0.1±0.1 vs. 0.2±0.6 mg/min, p=0.271). CONCLUSIONS: Use of diphenhydramine in our cohort was associated with a mean of 3.0 mcg/min lower fentanyl dose, equivalent to an average fentanyl dose reduction of 193mcg per procedure. Further randomized controlled trials with a protocol for sedation including diphenhydramine or placebo would be the next endeavor to fully evaluate this hypothesis. CLINICAL IMPLICATIONS: Diphenhydramine appears to reduce fentanyl requirements and therefore should be considered as adjuctive therapy for moderate sedation in EBUS procedures. DISCLOSURES: No relevant relationships by Abdallah Abboud, source=Web Response No relevant relationships by Sonia Castillo, source=Web Response

Evaluation of Intravenous Diphenhydramine Use in Patients with Sickle Cell Vaso-Occlusive Crisis.

Purpose: To compare the incidence of oversedation between oral and parenteral diphenhydramine therapy for treatment of opioid-induced pruritus in patients with sickle cell disease vaso-occlusive crisis (SCD VOC). Methods: This retrospective, single-center, cohort study included patients greater than or equal to 18 years old with sickle cell disease admitted for vaso-occlusive crisis who received either intravenous or oral diphenhydramine for opioid-induced pruritus. Patients were identified through ICD-9 and ICD-10 codes from June 1, 2016 through July 1, 2017. Rates of oversedation were compared between the 2 formulations. Secondary endpoints included length of stay, amount and duration of diphenhydramine, rate of acute chest and indication for IV therapy. Results: Fifty unique patients were included in the analysis representing 121 admissions. Seven patients received both formulations on separate admissions and were included in both groups. Twenty-nine percent of patients in the IV diphenhydramine group experienced oversedation (12/42) versus 13% in the oral diphenhydramine group (2/15, P = .312). The average number of admissions was significantly higher in the IV versus oral group (2.45 vs 1.20; P = .005) with average and median length of stay also significantly higher in the IV versus oral group (30.57, 16.0 vs 10.67, 10.0; P = .003). Conclusion: While there was no statistically significant difference in the rates of oversedation with use of IV versus oral diphenhydramine formulations, patients with SCD VOC who received IV diphenhydramine had more frequent admissions and a longer length of stay. Clinicians may consider oral diphenhydramine preferentially in appropriate patients over IV administration.

Intravenous Cetirizine Versus Intravenous Diphenhydramine for the Treatment of Acute Urticaria: A Phase III Randomized Controlled Noninferiority Trial

Acute urticaria is a frequent presentation in emergency departments (EDs), urgent care centers, and other clinical arenas. Treatment options are limited if diphenhydramine is the only intravenous antihistamine offered because of its short duration of action and well-known adverse effects. We evaluate cetirizine injection, the first second-generation injectable antihistamine, for acute urticaria in this multicenter, randomized, noninferiority, phase 3 clinical trial. Adult patients presenting to EDs and urgent care centers with acute urticaria requiring an intravenous antihistamine were randomized to either intravenous cetirizine 10 mg or intravenous diphenhydramine 50 mg. The primary endpoint was the 2-hour pruritus score change from baseline, with time spent in treatment center and rate of return to treatment centers as key secondary endpoints. Frequency of sedation and anticholinergic adverse effects were also recorded. Among 262 enrolled patients, the 2-hour pruritus score change from baseline for intravenous cetirizine was statistically noninferior to that for intravenous diphenhydramine (-1.6 versus -1.5; 95% confidence interval -0.1 to 0.3), and in favor of cetirizine. Treatment differences also favored cetirizine for mean time spent in treatment center (1.7 versus 2.1 hours; P=.005), return to treatment center (5.5% versus 14.1%; P=.02), lower change from baseline sedation score at 2 hours (0.1 versus 0.5; P=.03), and adverse event rate (3.9% versus 13.3%). Intravenous cetirizine is an effective alternative to intravenous diphenhydramine for treating acute urticaria, with benefits of less sedation, fewer adverse events, shorter time spent in treatment center, and lower rates of revisit to treatment center.

Intravenous Migraine Treatment in Children and Adolescents.

Pediatric migraine is a common, chronic, and disabling neurological disorder in children and adolescents. Outpatient management is not always effective, and intravenous migraine management may be necessary for headache treatment in the pediatric emergency department. Most current treatment is based on retrospective evidence and there is a lack of well-designed randomized double-blinded controlled pediatric studies. Intravenous drug treatment agents including intravenous fluids, prochlorperazine, diphenhydramine, metoclopramide, dexamethasone, magnesium, valproate and propofol, and dihydroergotamine are reviewed in this paper. Nineteen studies were reviewed including one prospective randomized double-blind; one single-blinded randomized; one prospective; and one open-label, randomized clinical trial. Most studies were retrospective and the quality of the studies was limited. No definite conclusions can be drawn from the studies, but appropriate prospective trials between major pediatric headache institutions will move pediatric intravenous migraine management forward.

A rare case of anaphylaxis to Indian jujube (Ziziphus Mauritiana Lam)

BackgroundIndian jujube (Ziziphus Mauritiana Lam) is a sweet fruit from a tree native to tropical and subtropical regions of Asia and India. A few case reports have implicated Indian jujube to cause latex-fruit syndrome. We present the first case of an anaphylactic reaction to this fruit in a patient with no latex allergy.Case presentationA 55-year-old male was referred to the Outpatient Allergy Clinic at Queen’s University for evaluation of anaphylaxis caused by ingestion of Indian jujube. He presented to the Emergency Department (ED) with scalp pruritus, dyspnea and generalized urticaria, which occurred two hours after he had consumed a homemade candied fruit cocktail consisting of Indian jujube, water, Thai and Indian sweetener. In the ED, he was treated with epinephrine, intravenous diphenhydramine and steroids. He did not have any previous history of environmental or food allergies but had consumed this fruit frequently since childhood. In clinic, he underwent skin-prick testing with a saline slurry of candied jujube, which resulted in a positive wheal and flare response with appropriate controls. On subsequent visit, skin-prick tests were performed with saline slurries of the Thai and Indian sweetener used to make the cocktail. Both tests were negative when applied to a healthy volunteer. Skin-prick testing to latex allergen and latex specific IgE were both negative. He was diagnosed with an IgE-mediated anaphylactic reaction to the Indian jujube fruit. He was advised to avoid consumption of Indian jujubes and carry an epinephrine autoinjector.ConclusionsAnaphylaxis secondary to Indian jujube ingestion is an extremely rare phenomenon in patients without a latex allergy. A possible allergy to Indian jujube should be taken into consideration when working up anaphylaxis, especially in patient of Asian and Indian descent who have ceased regular consumption of the fruit.