Key Hospitalist Clinical Practice Guidelines in 2017

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

January 16, 2018

In This Article

Anaphylaxis

American Academy of Pediatrics

Epinephrine is the medication of choice for the initial treatment of anaphylaxis. If injected promptly, it is nearly always effective. Delayed injection can be associated with poor outcomes, including fatality. All other medications, including H1-antihistamines and bronchodilators such as albuterol, provide adjunctive treatment but do not replace epinephrine.

After treatment with epinephrine for anaphylaxis in community settings, it is important for patients to be assessed in an emergency department to determine whether additional interventions, including oxygen, intravenous fluids, and adjunctive medications, are needed.

When anaphylaxis occurs in health care settings, epinephrine (0.01 mg/kg [maximum dose: 0.3 mg in a prepubertal child and up to 0.5 mg in a teenager]) by IM injection in the mid-outer thigh (vastus lateralis muscle) is recommended. IM epinephrine achieves peak epinephrine concentrations promptly and is safer than an intravenous bolus injection.

Epinephrine given by IM injection achieves peak concentrations faster than that given by subcutaneous injection. Epinephrine, 0.3 mg IM, is 10 times safer than epinephrine given as an intravenous bolus.

Serious adverse effects of IM epinephrine are rare in children. There is no absolute contraindication to epinephrine treatment in anaphylaxis.

When anaphylaxis occurs in community settings, epinephrine autoinjectors (EAs) are preferred because of their ease of use and accuracy of dosing as compared with the use of an ampule, syringe, and needle by laypersons or the use of an unsealed syringe prefilled with epinephrine.

In the United States and Canada, EAs are currently available in only 2 fixed doses: 0.15 mg and 0.3 mg. International guidelines suggest that when using EAs, patients weighing 7.5 kg (16.5 lb) to 25 kg (55 lb) should receive the 0.15-mg dose; although this dose is not ideal for those who weigh less than 15 kg (33 lb), the alternatives are associated with delay in dosing, inaccurate dosing, and potential loss of the dose.

It is reasonable to recommend EAs containing a 0.3-mg epinephrine dose for those weighing 25 kg (55 lb) or more.

EA manufacturers advise prescribing the 0.15-mg dose for patients weighing 15 to 30 kg and the 0.3-mg dose for those weighing 30 kg and over. These doses are optimal for many children but not necessarily for all children.

If the response to the first epinephrine injection is inadequate, it can be repeated once or twice at 5- to 15-minute intervals.

The 0.15-mg dose is high for infants (a twofold dose for those weighing ≤7.5 kg) and for some young children. Some EA manufacturers have suggested that an alternative approach for infants is to have caregivers draw up the dose from a 1-mL ampule by using a 1-mL syringe. However, dose preparation can take laypersons as long as 3 to 4 minutes; moreover, doses typically are inaccurate and can sometimes contain no epinephrine at all when the solution is ejected from the syringe along with the air. Although unsealed 1-mL syringes prefilled by a health care professional with infant epinephrine doses also have been recommended, the doses can be lost, and the epinephrine solution typically degrades within a few months as a result of air exposure.

It is beneficial to prescribe EAs for all patients who have experienced anaphylaxis and who may re-encounter their trigger in a community setting. If specific circumstances warrant, EAs may also be prescribed for some high-risk patients without a history of anaphylaxis.

Epinephrine is best prescribed in the context of a written, personalized anaphylaxis emergency action plan, developed by the medical home with input from the family. Protocols for the use of unassigned EAs may also be beneficial.

Children at risk of anaphylaxis require a comprehensive approach to management. It is important to teach patients and caregivers how to recognize anaphylaxis symptoms; when, why, and how to use an EA; and the rationale for calling 911 or EMS.

Children who have experienced anaphylaxis benefit from evaluation by an allergy/immunology specialist for confirmation of the diagnosis, confirmation of specific triggers, and preventive care.

References

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