A Retrospective Study of Epinephrine Administration for Anaphylaxis: How Many Doses Are Needed?

Abstract

The precise amount of epinephrine needed to reverse severe symptomatology due to an anaphylactic reaction is unknown. We tried to determine how frequently more than one injection of epinephrine is required to treat an anaphylactic reaction. A retrospective review of patient charts with anaphylactic reactions requiring epinephrine, in response to inhalant allergen and hymenoptera venom immunotherapy as well as live hymenoptera stings, examined type of reaction; number, doses, and timing of epinephrine administered; and ancillary treatment. A total of 105 anaphylactic reaction events of varying severity (Ring's classification) were recorded (54--Grade I, 29--Grade II, 18--Grade III, 0--Grade IV, 4--unknown). The median epinephrine dose administered was 0.3 cc (range 0.1 to 0.8 cc, 1:1000). The timing of the first epinephrine injection was < or = 5 minutes in 27, 6-10 minutes in 13, 11-30 minutes in 16, < or = 30 minutes in 32, 31-60 minutes in 12, and > 60 minutes in five epinephrine treated patients. Overall, 38 patients (35.5%; CI95, 26.4-44.6%) required > 1 epinephrine injection. Of these, 11 experienced Grade I (11/54-20.3%; CI95, 9.6-31.0%), 12--Grade II (12/29-41.5%, CI95, 23.5-59.3%), and 13--Grade III (13/18-72.2%, CI95, 51.5-92.9%); reactivity was unknown in 2 patients. Forty-four patients also received an antihistamine, 10 received corticosteroids, and 30 received both medications and/or other ancillary therapy. A significant number of patients (> 35%) with anaphylactic reactions received greater than one epinephrine dose to manage events for the three classes of severity. Patients at risk for anaphylaxis and their caregivers need to recognize that more than one dose of epinephrine may be required for treatment of anaphylaxis.

Kurzdarstellung

“…Ausgebildete Ersthelfer können bei dieser Maßnah-me unterstützen. Geben Sie allen Personen mit einer Anaphylaxie im präklini-schen Bereich eine zweite intramuskuläre Adrenalindosis, wenn sich die Symptome innerhalb von 5-15 min nach der Anwendung eines intramuskulären AdrenalinAutoinjektors nicht gebessert haben [843][844][845][846][847][848][849][850][851][852]. Auch bei einem Wiederauftreten der Symptome kann eine zweite intramuskuläre Dosis Adrenalin notwendig sein.…”

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

“…Em um estudo realizado com 582 pacientes com anafilaxia, 45 (8%) exigiram doses múltiplas de adrenalina 19 . Outro estudo com 105 pacientes demonstrou que 35,5% necessitaram de mais de uma dose de adrenalina para controle da anafilaxia 20 . O conhecimento do intervalo correto é importante, principalmente para evitar reações adversas relacionadas a aplicações em intervalos menores de cinco minutos.…”

Actualización en las recomendaciones del tratamiento del choque anafiláctico: novedades sobre el uso de adrenalina

“…Esta revisión destaca las problemáticas que pueden existir entre las distintas poblaciones estudiadas, sobre todo las dificultades que se encuentran en los adolescentes. 41 Algunos pacientes pueden requerir una segunda dosis de adrenalina durante el rescate dependiendo del origen de la anafilaxia [42][43][44][45][46] y, en ciertas oportunidades, se debe indicar la provisión de dos dosis de autoinyectores. 47 Aunque, en las reacciones graves, el uso de adrenalina podría disminuir notoriamente los costos directos relacionados con la anafilaxia por disminución de internaciones y de tratamientos más extremos, en las reacciones leves por picaduras de insectos, no ha demostrado una efectividad relevante relacionada con el costo-beneficio.…”