Multiple Doses Of Epinephrine Research Articles

Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis.

Epinephrine can be a life-saving treatment for patients with anaphylaxis. Potential cardiovascular side effects of epinephrine may contribute to clinician hesitancy to use it. However, the frequency of cardiotoxicity resulting from epinephrine treatment for anaphylaxis is not well described. We sought to describe the frequency of cardiotoxicity following intramuscular (IM) administration of epinephrine in adult emergency department (ED) patients with anaphylaxis. We conducted a retrospective observational study at a single, quaternary care academic ED in Tennessee. We identified consecutive ED visits with the diagnosis of anaphylaxis from 2017 to 2021 who received at least one intramuscular (IM) dose of epinephrine in the ED. Analysis was primarily descriptive. The primary outcome was cardiotoxicity, the occurrence of any of the following after epinephrine administration: ischemic electrocardiogram changes, systolic blood pressure>200mmHg, or cardiac arrest ≤4h; elevated troponin ≤12h; or percutaneous coronary intervention or depressed ejection fraction ≤72h. Among 338 included patients, 16 (4.7%; 95%CI: 2.8-7.6%) experienced cardiotoxicity. Cardiotoxic events included eight (2.4%) ischemic electrocardiogram changes, six (1.8%) episodes of elevated troponin, five (1.5%) atrial arrhythmias, one (0.3%) ventricular arrythmia, and one (0.3%) depressed ejection fraction. Patients with cardiotoxicity were significantly older, had more comorbidities, and were more likely to have received multiple doses of epinephrine or an epinephrine infusion compared with a single IM dose of epinephrine. Among 338 consecutive adult ED patients who received IM epinephrine for anaphylaxis during a recent 4-year period, cardiotoxic side effects were observed in approximately 5% of patients.

SYSTEMIC MASTOCYTOSIS WITH CONCURRENT ALPHA-GAL ASSOCIATED ANAPHYLAXIS

<h3>Introduction</h3> We present a case of a patient, diagnosed with systemic mastocytosis (SM), who was also found to have anaphylaxis to galactose-α-1,3-galactose (alpha-gal) several years after his initial SM diagnosis. <h3>Case Description</h3> The patient initially presented in his 20s with recurrent episodes of hypotension, pre-syncope, and syncope. An extensive cardiac and neurologic workup did not elucidate an etiology. He moved to Mississippi and had a six-year period with no episodes. In 2015, he was admitted to the intensive care unit due to presumed septic shock secondary to an infected pilonidal cyst. A tryptase level during hospitalization was elevated at >30, and a bone marrow biopsy confirmed the diagnosis of indolent SM. After starting antihistamines, the patient was initially free of anaphylaxis episodes. The patient then began experiencing weekly anaphylactic episodes, often with severe hypotension, sometimes requiring multiple doses of epinephrine. Episodes persisted despite increased antihistamine regimen. After extensive testing, he was found to have elevated alpha-gal specific IgE and was diagnosed with alpha-gal-associated anaphylaxis. With mammalian meat avoidance, he had no further anaphylactic episodes. <h3>Discussion</h3> Our reports highlight the importance of considering food allergens, particularly alpha-gal, in locations with a high incidence of lone star tick bites, as possible triggers for recurrent anaphylaxis in patients with SM. Given the delayed presentation of alpha-gal reactions and the inherent propensity for patients with SM to experience anaphylaxis, this diagnosis can easily be overlooked. The case also suggests the possibility that underlying SM may be associated with more severe manifestations of alpha-gal reaction.

One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study

Background Cardiac arrest guidelines recommend epinephrine every 3–5 minutes during cardiac arrest resuscitation. However, it is unclear if multiple epinephrine doses are associated with improved outcomes. The objective of this study was to determine if a single-dose epinephrine protocol was associated with improved survival compared to traditional multidose protocols. Methods We conducted a pre-post study across five North Carolina EMS agencies from 11/1/2016 to 10/29/2019. Patients ≥18 years old with attempted resuscitation for non-traumatic prehospital cardiac arrest were included. Data were collected 1 year before and after implementation of the single-dose epinephrine protocol. Prior to implementation, all agencies used a multidose epinephrine protocol. The Cardiac Arrest Registry to Enhance Survival (CARES) was used to obtain patient outcomes. Study outcomes were survival to hospital discharge (primary) and return of spontaneous circulation (ROSC). Analysis was by intention to treat. Outcomes were compared pre- vs. post-implementation using generalized estimating equations to account for clustering within EMS agencies. Adjusted analyses included age, sex, race, shockable vs. non-shockable rhythm, witnessed arrest, automatic external defibrillator availability, EMS response interval, and bystander cardiopulmonary resuscitation. Results During the study period there were 1,690 encounters (899 pre- and 791 post-implementation). The population was 74.7% white, 61.1% male, and had a median age of 65 (IQR 53–76) years. Survival to hospital discharge was similar pre- vs. post-implementation [13.6% (122/899) vs. 15.4% (122/791); OR 1.19, 95%CI 0.89–1.59]. However, ROSC was more common post-implementation [42.3% (380/899) vs. 32.5% (257/791); OR 0.66, 95%CI 0.54–0.81]. After adjusting for covariates, the single-dose protocol was associated with similar survival to discharge rates (aOR 0.88, 95%CI 0.77–1.29), but with decreased ROSC rates (aOR 0.58, 95%CI 0.47–0.72). Conclusion A prehospital single-dose epinephrine protocol was associated with similar survival to hospital discharge, but decreased ROSC rates compared to the traditional multidose epinephrine protocol.

Sesame-induced anaphylaxis in pediatric patients from the cross-Canada anaphylaxis registry

BackgroundSesame can cause severe allergic reactions and is a priority allergen in Canada. ObjectiveTo assess clinical characteristics and management of pediatric sesame-induced anaphylaxis and identify factors associated with epinephrine treatment. MethodsBetween 2011 and 2021, children with sesame-induced anaphylaxis presenting to 7 emergency departments (ED) in 4 Canadian provinces and 1 regional emergency medical service were enrolled in the Cross-Canada Anaphylaxis Registry. Standardized recruitment forms provided data on symptoms, severity, triggers, and management. Multivariate logistic regression evaluated associations with epinephrine treatment pre-ED and multiple epinephrine dosages. ResultsOf all food-induced anaphylactic reactions (n = 3279 children), sesame accounted for 4.0% (n = 130 children), of which 61.5% were boys, and the average (SD) age was 5.0 (4.9) years. Hummus containing sesame paste triggered 58.8% of reactions. In the pre-ED setting, 32.3% received epinephrine, and it was more likely to be used in boys (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.08-1.50) and those with a known food allergy (aOR, 1.36; 95% CI, 1.11-1.68]). In the ED, 47.7% of cases received epinephrine, with older children more likely to receive multiple epinephrine doses (aOR, 1.00; 95% CI, 1.00-1.02). ConclusionIn Canada, hummus is the major trigger of sesame-induced anaphylaxis. Knowledge translation focused on prompt epinephrine use and product-labeling policies are required to limit sesame reactions in communities.

Acute At-Home Management of Anaphylaxis: 911: What Is the Emergency?

The appropriate at-home management of anaphylaxis begins with patient education on recognition and treatment, especially when and how to use epinephrine. Delayed administration of epinephrine as well as having severe symptoms and needing multiple doses of epinephrine to treat symptoms are risk factors for biphasic anaphylaxis. The successful implementation of at-home management of anaphylaxis requires appropriate patient selection and an algorithmic approach that recommends activation of emergency medical services (EMS) when the patient does not adequately respond to at-home administration of epinephrine or there are extenuating patient-related circumstances. Fortunately, approximately 98% of anaphylactic episodes respond to 2 or fewer doses of epinephrine, the standard prescription used for epinephrine autoinjectors; fatal anaphylaxis is very rare, as low as 0.002 deaths/million person-years; and biphasic reactions are uncommon (∼5%), and only extremely rarely lethal. Thus, most common concerns leading to recommended EMS activation and emergency department visits after epinephrine administration are generally unsubstantiated. Furthermore, emergency department visits do not always lead to better treatment and drive health care costs higher. Open communications with patients and families regarding risks and benefits of at-home management and observation versus EMS activation and emergency department evaluation after epinephrine administration for anaphylaxis are essential. However, we believe the data indicate that it is time to reconsider the often used and taught approach that recommends EMS activation whenever epinephrine is used.

A Case Report of Prolonged Anaphylaxis after COVID-19 Vaccine.

IntroductionAs the medical community and world have combatted the coronavirus disease 2019 (COVID-19) pandemic, a significant advance was the development of a vaccine against the virus that has already claimed over 4.5 million lives worldwide.1 Vaccines manufactured by Pfizer-BioNTech and Moderna were the first two COVID-19 vaccines given emergency use authorization by the United States Food and Drug Administration. Preliminary data demonstrated not only the vaccines’ efficacy rates of greater than 95% after a second dose, but also marked safety. Initial data showed only 21 cases of anaphylaxis of greater than 1.8 million doses administered. The majority of those patients had a history of anaphylaxis and presented within the first 15 minutes after administration of the vaccine.2Case ReportWe describe a patient who had an anaphylactic reaction to her second dose of the Pfizer BioNTech severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) vaccine with no prior history of allergic reactions or anaphylaxis. This reaction required multiple doses of epinephrine and a four-day hospitalization. We review both the available reports of anaphylaxis to the SAR CoV-2 vaccine and information on other prolonged cases of anaphylaxis.ConclusionOur case report is unique in that the patient, despite no prior history of anaphylaxis, had a prolonged course requiring a four-day hospitalization. To our knowledge this is one of the first case reports of prolonged anaphylaxis after the second dose of Pfizer BioNTech COVID-19 vaccine in a patient with no history of prior anaphylaxis.3

Use of multiple epinephrine doses in anaphylaxis: A systematic review and meta-analysis

BackgroundRegulatory bodies recommend that all patients at risk of anaphylaxis be prescribed 2 epinephrine autoinjectors, which they should carry at all times. This is in contrast to some guidelines. The proportion of anaphylaxis reactions that are treated with multiple doses of epinephrine has not been systematically evaluated.ObjectiveOur aim was to undertake a systematic review and meta-analysis of published studies reporting epinephrine treatment for anaphylaxis in which data relating to the number of doses administered were available.MethodsWe searched the Medline, Embase, and Cochrane databases for relevant studies reporting at least 10 anaphylaxis events (due to food or venom) from 1946 until January 2020. Data were extracted in duplicate for the meta-analysis, and the risk of bias was assessed. The study was registered under the PROSPERO identifier CRD42017069109.ResultsA total of 86 studies (36,557 anaphylaxis events) met the inclusion criteria (20 of the studies [23%] were prospective studies; 64 [74%] reported reactions in the community, and 22 [26%] included food challenge data). Risk of bias was assessed as low in 50 studies. Overall, 7.7% of anaphylaxis events from any cause (95% CI = 6.4-9.1) were treated with multiple doses of epinephrine. When only epinephrine-treated reactions for which subsequent doses were administered by a health care professional were considered, 11.1% of food-induced reactions (95% CI = 9.4-13.2) and 17.1% of venom-induced reactions (95% CI = 11.3-25.0) were treated with more than 1 epinephrine dose. Heterogeneity was moderate to high in the meta-analyses, but at sensitivity analysis this estimate was not affected by study design or anaphylaxis definition.ConclusionAround 1 in 10 anaphylaxis reactions are treated with more than 1 dose of epinephrine.

Shorter Dosing Interval Is Associated With Multiple Doses Of Epinephrine Required To Resolve Allergic Reaction At Milk Oral Challenge

Shorter Dosing Interval Is Associated With Multiple Doses Of Epinephrine Required To Resolve Allergic Reaction At Milk Oral Challenge

A Cost-Effectiveness Analysis of Epinephrine Autoinjector Risk Stratification for Patients with Food Allergy—One Epinephrine Autoinjector or Two?

Food-allergic patients are routinely prescribed 2 epinephrine autoinjectors (EAIs). The cost-effectiveness of this strategy is unknown. To evaluate the cost-effectiveness of routinely prescribing all patients 2 EAI devices versus a risk-stratified approach (2 EAIs prescribed only for patients with a risk factor). Markov models compared universal versus risk-stratified approaches on the basis of either a previous medical history of anaphylaxis (PMH-ana) or anaphylaxis requiring multiple epinephrine doses (multi-epi). Cohorts of children with peanut allergy were evaluated over an 80-year time horizon from both US and UK societal and health care perspectives. Models assumed prescribing a second EAI provided a baseline 10-fold risk reduction versus anaphylaxis-related fatality and hospitalization. Cost-effectiveness threshold was $100,000/quality-adjusted life-year (QALY). From a US perspective, universal prescription of 2 EAIs to all patients with peanut allergy was not cost-effective in the base case versus risk stratification by PMH-ana. Universal prescription of 2 EAIs was associated with an incremental cost of $10,696,036/QALY versus the PMH-ana strategy, and $17,514,558/QALY versus the multi-epi strategy. However, the universal strategy became cost-effective versus a multi-epi strategy when single EAI costs were less than $80, second epinephrine dose requirements more than 25.5%, anaphylaxis hospitalization costs more than $18,453, annual anaphylaxis risk more than 76.5%, or anaphylaxis hospitalization rate more than 74.9%. From a UK perspective, universally prescribing 2 EAIs was also not cost-effective (incremental cost of $4,132,440/QALY vs PMH-ana and $6,208,227/QALY vs multi-epi) at single device costs more than $18. At current EAI prices and low rates of needing 2 devices, limiting the second EAIs to patients with PMH-ana is more cost-effective than routinely prescribing 2 EAIs to all patients (particularly in resource-constrained settings).

Type I allergic reaction to rituximab upon first lifetime exposure: a case report

BackgroundWhile drug reactions to rituximab have been commonly reported in the literature, a type I allergic reaction to rituximab after first lifetime exposure has never been reported.Case presentationWe describe a case of a 58-year-old female patient who received rituximab for the first time for treatment of rheumatoid arthritis. She developed symptoms immediately after infusion, however presented 11 days after drug exposure with cyclical anaphylaxis-like reaction requiring multiple doses of epinephrine. On second exposure, she experienced immediate anaphylaxis 30 min into infusion.ConclusionOur case illustrates the importance of heightened awareness by physicians that type I IgE-mediated reactions after first exposure to monoclonal antibodies such as rituximab are possible, and if unrecognized, could be potentially life-threatening.

Prehospital Epinephrine as a Potential Factor Associated with Prehospital Rearrest

Objective: To investigate the impact of epinephrine on prehospital rearrest and re-attainment of prehospital return of spontaneous circulation (ROSC). Methods: Data for 9,292 (≥ 8 years) out-of-hospital cardiac arrest (OHCA) patients transported to hospitals by emergency medical services were collected in Ishikawa Prefecture, Japan during 2010–2018. Univariate and multivariable analyses were retrospectively performed for 1,163 patients with prehospital ROSC. Results: Of 1,163 patients, rearrest occurred in 272 (23.4%) but not in 891 (76.6%). Both single and multiple doses of epinephrine administered before prehospital ROSC (adjusted odds ratio (OR): 3.62, 95% confidence interval (CI): 2.42–5.46 for 1 mg, and 4.27, 2.58–6.79 for ≥ 2 mg) were main factors associated with rearrest. The association between initial and rearrest rhythms was significantly associated with epinephrine administration (p = 0.02). However, the rearrest rhythm was primarily associated with the initial rhythm (p < 0.01). The majority of patients with the non-shockable initial rhythm had pulseless electrical activity (PEA) as the rearrest rhythm, regardless of epinephrine administration (80.4% for administration, 81.6% for no administration). When the initial rhythm was shockable, the primary rearrest rhythms in patients with and without epinephrine administration before prehospital ROSC were PEA (52.2%) and ventricular fibrillation/pulseless ventricular tachycardia (56.8%), respectively. Only epinephrine administration after rearrest was associated with prehospital re-attainment of ROSC (adjusted OR: 2.49, 95% CI: 1.20–5.19). Stepwise multivariable logistic regression analyses revealed that neurologically favorable outcome was poorer in patients with rearrest than those without rearrest (9.9% vs. 25.0%, adjusted OR: 0.42, 95% CI: 0.23–0.73). The total prehospital doses of epinephrine were associated with poorer neurological outcome in a dose-dependent manner (adjusted OR: 0.22, 95% CI: 0.13–0.36 for 1 mg; 0.09, 0.04–0.19 for 2 mg; 0.03, 0.01–0.09 for ≥ 3 mg, no epinephrine as a reference). Transportation to hospitals with a unit for post-resuscitation care was associated with better neurological outcome (adjusted OR: 1.53, 95% CI: 1.02–2.32). Conclusions: The requirement for epinephrine administration before prehospital ROSC was associated with subsequent rearrest. Routine epinephrine administrations and rearrest were associated with poorer neurological outcome of OHCA patients with prehospital ROSC.

Risk Factors for Multiple Epinephrine Doses in Food-Triggered Anaphylaxis in Children

To examine risk factors of multiple-dose epinephrine treatment in pediatric food-induced anaphylaxis.In a total of 642 surveys, participants reported allergic reactions. The median age of the child was 2.5 years, 59% were boys, and 77% were white. Allergy to peanut and tree nut were the most common in this population. Prospective follow-up data were collected from the same respondents at median age 7.5 years.Between 2009 and 2011, families of children with food allergy at the Jaffe Food Allergy Institute were randomly selected to complete a questionnaire evaluating demographics, atopic history, and number of reactions requiring epinephrine. Follow-up data on reaction details were prospectively collected.History of asthma or report of respiratory symptoms during a reaction increased the odds of requiring any epinephrine. Eleven percent of reactions required multiple doses of epinephrine. Milk-triggered reactions were 3 times more likely to require multiple doses of epinephrine than reactions caused by other foods. In reactions that required multiple doses of epinephrine, the initial dose was more likely to be given by emergency medical services, not a child’s immediate caregiver. Reactions managed with oxygen were also more likely to require more than 1 dose of epinephrine.This is the first study evaluating the need for multiple doses of epinephrine in young pediatric patients. A significant number of food-induced anaphylaxis cases required multiple doses of epinephrine, especially those triggered by milk or treated with oxygen, and 11% of the children required multiple doses of epinephrine. This emphasizes the importance of carrying 2 autoinjectors.Although nut allergy was the most common reported allergy, reactions to milk were the most likely to require multiple doses of epinephrine in this young cohort. Families often separate the autoinjectors in a kit and must be counseled on the importance of having 2 autoinjectors available at all times. Caregivers must be empowered to administer epinephrine immediately in cases of anaphylaxis. Prompt epinephrine administration, occasionally multiple doses, is paramount and lifesaving.

A Synopsis of the Synopses, 2018 to 2019

With this Synopsis Book, we provide reviews on a range of observations and advances that will increase understanding of allergic and immunologic disorders impacting children. These findings can influence clinical practice now and in the near future. Reviewers have selected notable articles that will help improve patient care through optimizing diagnosis and management and raising awareness of modifiable risk factors and novel therapeutic targets. There continues to be tremendous interest in identifying potential risk factors for the development of allergic disorders, with much attention on the role of the microbiome as well as other modifiable risks, such as antioxidants, vitamin D, and ultraviolet radiation exposure. Although associations are reported in some studies, significant shifts in allergy risk have not been demonstrated in interventional studies. Multiple factors are likely in play with complex interactions; therefore, further exploration in these realms is required to determine if these or other risk factors can be modified to mitigate allergy risk. The role of diet in the development of allergic disease remains an area of significant interest. Early introduction of peanut for allergy prevention is supported by national guidelines, and efforts have focused on dissemination …

Evaluation of Prehospital Management in a Canadian Emergency Department Anaphylaxis Cohort

Studies assessing the use of antihistamines and corticosteroids for the treatment of anaphylaxis have not supported a conclusive effect. To assess prehospital management of anaphylaxis by measuring the effect of epinephrine use compared with antihistamines and corticosteroids on negative outcomes of anaphylaxis (intensive care unit/hospital ward admission, multiple doses of epinephrine in the emergency department [ED], and intravenous fluids given in the ED). The Cross-Canada Anaphylaxis Registry is a cohort study that enrolls anaphylaxis cases presenting to EDs in 5 Canadian provinces over a 6-year period. Participants were recruited prospectively and retrospectively and were excluded if the case did not meet the definition of anaphylaxis. A total of 3498 cases of anaphylaxis, of which 80.3% were children, presented to 9 EDs across Canada. Prehospital treatment with epinephrine was administered in 31% of cases, whereas antihistamines and corticosteroids were used in 46% and 2% of cases, respectively. Admission to the intensive care unit/hospital ward was associated with prehospital treatment with corticosteroids (adjusted odds ratio, 2.84; 95% confidence interval [CI], 1.55, 6.97) while adjusting for severity, treatment with epinephrine and antihistamines, asthma, sex, and age. Prehospital treatment with epinephrine (adjusted odds ratio, 0.23; 95% CI, 0.14, 0.38) and antihistamines (adjusted odds ratio, 0.61; 95% CI, 0.44, 0.85) decreased the likelihood of receiving multiple doses of epinephrine in the ED, while adjusting for severity, treatment with corticosteroids, asthma, sex, and age. Prompt epinephrine treatment is crucial. Use of antihistamines in conjunction with epinephrine may reduce the risk of uncontrolled reactions (administration of 2 or more doses of epinephrine in the ED), although our findings do not support the use of corticosteroids.

Anaphylaxis risk factors for hospitalization and intensive care: A comparison between adults and children in an upstate New York emergency department.

Background: Anaphylaxis is an acute, systemic allergic reaction that can be life threatening, and with an increasing incidence and costs associated with hospitalization and intensive care. Objective: To assess the risk factors for hospitalization by comparing pediatric and adult patients. Methods: We performed a retrospective chart review for patients with anaphylactic reactions who presented to the Albany Medical Center emergency department between 2005 and 2012. Results: We identified 267 anaphylactic reactions in 258 patients (143 adults). Of those, 128 (48%) were not coded as anaphylaxis despite fulfilling diagnostic criteria. Foods were the most common trigger both in adults and children. Factors associated with increased odds of hospitalization (intensive care unit [ICU] and hospital floor combined) included a severity score of 3 in both children (odds ratio [OR] 41.86 [95% confidence interval {CI}, 2.9-602.48], p = 0.006) and adults (OR 32.52 [95% CI, 6.28-168.35], p < 0.001), and those who received multiple doses of epinephrine in children (OR 15.36 [95% CI, 1.9-121.4], p = 0.009) and adults (OR 11.49 [95% CI, 3.08-44.13], p < 0.001). Patient characteristics associated with ICU admission in children and adults combined included Medicare and/or Medicaid insurance (OR 4.96 [95% CI, 1.14-21.67], p = 0.023), cutaneous symptoms (OR 0.19 [95% CI, 0.04-0.79], p = 0.23), and cardiovascular symptoms (OR 5.8 [95% CI, 1.16-28.87], p = 0.032). Conclusion: Anaphylaxis remains underrecognized and improperly treated in the emergency department. Severity of symptoms and receiving multiple doses of epinephrine were associated with hospitalization in both children and adults. Medicare and/or Medicaid insurance, and cardiovascular or cutaneous symptoms were characteristics associated with ICU admission in our cohort.

Risk factors for multiple epinephrine doses in food-triggered anaphylaxis in children

BackgroundFood-related anaphylactic reactions may require treatment with more than 1 dose of epinephrine. Current guidelines advise patients at risk of anaphylaxis to carry 2 epinephrine autoinjectors. ObjectiveThe objective of this study was to determine risk factors of multiple-dose epinephrine treatment in pediatric food-related anaphylaxis. MethodsParents of children with physician-confirmed diagnosis of food allergy were administered a standardized questionnaire at the time of their clinic visit. These patients were then followed-up prospectively by phone. ResultsSix hundred forty-two subjects had allergic reactions. Twenty-six percent of patients reported at least 1 reaction treated with epinephrine, for a total of 221 reactions. Among reactions treated with epinephrine, 24 reactions (11%) received 2 or more doses of epinephrine. The most common triggers were milk (30%) and peanut (18%). Milk-triggered allergic reactions (odds ratio [OR] 3.2; 95% confidence interval [CI] 1.2–8.4) and treatment with oxygen (OR 5.0, 95% CI 2.0–12.4) were significant risk factors for requiring multiple doses of epinephrine to treat an allergic reaction. ConclusionThis study demonstrates that treatment of anaphylaxis may require more than 1 epinephrine injection. Reactions triggered by milk or requiring treatment with oxygen are at higher risk for needing more than 1 dose of epinephrine. Families of food-allergic children should be counseled on the importance of carrying 2 epinephrine auto-injectors.

Familial Anaphylaxis after Silkworm Ingestion

Herein, we present a case of anaphylaxis in multiple family members after ingesting silkworms, an Asian delicacy. While food allergies, including anaphylaxis are unfortunately common, there are no previous reports of multiple family members suffering an anaphylactic reaction after eating silkworms. In addition, both family members required multiple doses of epinephrine and eventually an epinephrine infusion to improve their blood pressures. All interventions, including the epinephrine infusions, were started by emergency medical services (EMS) with on-line medical direction. Both the reaction and the required treatment are not extensively documented in the medical literature.

Epinephrine induced cardiomyopathy in a child with anaphylaxis

Transient cardiomyopathy is an uncommon occurrence in patients with anaphylaxis. Catecholamine induced direct toxicity is one of the proposed mechanisms. We report a case of cardiomyopathy in a child with anaphylaxis who was treated with multiple doses of epinephrine as well as a continuous infusion of epinephrine. A twenty one month old girl with egg allergy presented to our hospital with anaphylaxis, after multiple doses of epinephrine injections, developed cardiorespiratory dysfunction and required endotracheal intubation and mechanical ventilation. Work up showed depressed cardiac function, which improved with milrinone and furosemide infusions. Conclusion: Epinephrine is the treatment of choice for anaphylaxis however caution should be exercised when administering multiple doses of epinephrine. Myocardial function needs to be assessed in children with persistent hypotension after anaphylaxis and catecholamine-induced cardiomyopathy should be considered in children with anaphylaxis when severe myocardial dysfunction is present.

Predictors of Repeat Epinephrine Administration for Emergency Department Patients with Anaphylaxis

Risk factors that predict which patients with anaphylaxis might require repeat doses of epinephrine are poorly understood. The objective of this study was to identify risk factors associated with the need for multiple doses of epinephrine during an anaphylactic reaction. Patients were included if they met diagnostic criteria for anaphylaxis on presentation to the emergency department (ED) at our academic medical center between April 2008 and February 2014. Data were collected on allergic history, presenting signs and symptoms, anaphylaxis management, and disposition. Univariable and multivariable analyses were performed to estimate associations between possible risk factors and the need for multiple doses. Of 582 ED patients with anaphylaxis, 45 (8%) required multiple doses of epinephrine. By multivariable analysis, factors associated with the need for repeat doses were a history of anaphylaxis (odds ratio [OR], 2.5 [95% CI, 1.3-4.7]; P = .005), the presence of flushing or diaphoresis (OR, 2.4 [95% CI, 1.3-4.5]; P = .007), and the presence of dyspnea (OR, 2.2 [95% CI, 1.0-5.0]; P = .046). Patients who received more than 1 dose were more likely to be admitted to the general medical floor (OR, 2.8 [95% CI, 1.1-7.2]; P = .03) or intensive care unit (OR, 7.6 [95% CI, 3.7-15.6]; P < .001). Patients with a history of anaphylaxis, flushing or diaphoresis, or dyspnea may require multiple doses of epinephrine to treat anaphylactic reactions. Patients who require more than 1 dose are more likely to be admitted to the hospital, thus increasing health care resource utilization.

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Introduction: Twenty-one-month old female with past medical history of egg allergy, presented to our hospital emergency room with perioral rash, emesis, cough, and generalized itching. One hour prior to admission she had meat loaf (containing milk, eggs). Child was given an antihistaminic medication and brought to emergency room. In the emergency room, patient received three doses of epinephrine 0.01mg/kg (1:1000 concentration; one dose IM and two doses IV) and racemic epinephrine nebulization over a period of twenty minutes for respiratory distress. Work of breathing continued to get worse and she became hypotensive. Three normal saline boluses of 20ml/kg each were given for hypotension and she was started on epinephrine drip at 1 mcg/kg/min in the emergency room before transferring the child to PICU. In PICU, the child had increased work of breathing, tachycardia (180-200 bpm) and poor peripheral perfusion. Child was intubated in the PICU and was placed on mechanical ventilator. She started developing pink frothy secretions. X-ray chest was consistent with pulmonary edema. EKG showed sinus tachycardia with nonspecific ST T wave changes and an echocardiogram revealed depressed left ventricular systolic function with an ejection fraction of 44%. Initial troponin (3.2 ng per ml), CPK-MB (11.5 ng per ml) and beta type natriuretic peptide (5000 pg per ml) levels were elevated. She was started on milrinone and lasix drips and epinephrine drip was weaned off. Over the next ten days, serial echocardiograms showed improvement in cardiac function with a final ejection fraction of 69% and normalization of cardiac enzymes. Child was discharged home fourteen days after admission. Discussion: Children with severe anaphylaxis may present with non-cardiogenic pulmonary edema and vasodilatory shock. However, in our patient clinical status worsened after starting epinephrine therapy and her cardiac enzymes were elevated along with cardiac dysfunction suggesting myocardial injury. As the child improved once the epinephrine was stopped catecholamine induced cardiomyopathy is a distinct possibility. Epinephrine is the cornerstone of anaphylaxis treatment. However, it has a narrow therapeutic index and can results in serious side effects. It is known that high dose of epinephrine administration can cause myocardial stunning and global myocardial hypokinesis. Diffuse myocardial injury was observed in experimental studies with excessive catecholamines. Such changes are also seen in patients with catecholamine excess states like, pheochromocytoma, stress induced cardiomyopathy (Tako-tsubo cardiomyopathy), and neurogenic myocardial stunning. This child was managed with ventilatory support, milrinone infusion and discontinuation of epinephrine. In refractory cases ECMO may be needed as a temporary support. Catecholamine induced cardiomyopathy is reversible within days to weeks. Caution should be exercised giving multiple doses of epinephrine for the management of anaphylaxis. Catecholamine induced cardiomyopathy should be considered in a child with poor cardiac function and high dose of epinephrine.