Epinephrine use in older patients with anaphylaxis: Clinical outcomes and cardiovascular complications

Kawano, Takahisa; Scheuermeyer, Frank; Stenstrom, Robert; Rowe, Brian H.; Grafstein, Eric; Grunau, Brian

doi:10.1016/j.resuscitation.2016.12.020

Cited by 36 publications

(28 citation statements)

References 19 publications

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“…This may be due to underlying physiopathological conditions, not clinically noticeable yet in these patients but which may play a role during anaphylaxis and adrenaline treatment. This is in line with the results of Kawano et al [17], who recently published a retrospective study in which older patients experienced cardiovascular complications, compared to a younger group (unadjusted OR 22.4; 95% CI: 2.1-1129.8). We could not find an association with previous cardiac disease or high blood pressure, or the use of specific drugs, but the number of patients with such medical history was very few within the sample.…”

Section: Discussionsupporting

confidence: 91%

Safety of Adrenaline Use in Anaphylaxis: A Multicentre Register

Cardona

Ferré-Ybarz²,

Guilarte³

et al. 2017

Int Arch Allergy Immunol

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Background: The use of intramuscular adrenaline to treat anaphylaxis is suboptimal, despite being the first-line treatment recommended by national and international anaphylaxis guidelines. Fear of potentially severe side effects may be one of the underlying factors. The aim of this study was to assess the incidence and severity of adverse side effects after the use of adrenaline in anaphylaxis, as well as potential risk factors. Methods: Observational study based on a multicenter online registry of cases of adrenaline administration for suspected anaphylaxis. Results: 277 registered valid cases were included: 138 (51.49%) female, median age 29 years (12-47), and 6 children under 2 years with a median age of 9 months (1-21). Side effects occurred in 58 cases (21.64%), with tremors, palpitations, and anxiety being the most frequent. There was a significant association of developing side effects with older age, higher dose of adrenaline, or use of the intravenous route. Potentially severe adverse effects (high blood pressure, chest discomfort, or ECG alterations) occurred only in 8 cases (2.99%); in these cases, no differences were found according to age or adrenaline dose, but again, intravenous administration was associated with more severe adverse events. Conclusion: This study shows that side effects affect less than 1 in 5 patients who receive adrenaline for an anaphylactic reaction, and are usually mild and transient. Therefore, in an emergency situation such as anaphylaxis, restricting adrenaline administration due to potential adverse effects would, in general, not be justified.

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Section: Discussionsupporting

confidence: 91%

Safety of Adrenaline Use in Anaphylaxis: A Multicentre Register

Cardona

Ferré-Ybarz²,

Guilarte³

et al. 2017

Int Arch Allergy Immunol

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“…31,32 During anaphylaxis, high doses of intravenously injected epinephrine have been reported to cause cardiovascular complications including arrhythmia, myocardial infarction and stress cardiomyopathy. 11,12 Several authors are reporting cases of stress cardiomyopathy following anaphylaxis, which could be attributed to the anaphylaxis itself, or to inappropriately high doses of epinephrine. 28,33 Epinephrine remains the first-line treatment of F I G U R E 4 Time course of the right gastrocnemius muscular PtiO 2 in SHAM (vehicle only, no shock), SHOCK (shock, no treatment), ABT (treatment with ABT-491), EPI (treatment with epinephrine) and EPI-ABT (treatment with both epinephrine and ABT-491) groups (n = 10 per groups).…”

Section: Discussionmentioning

confidence: 99%

“…Its use was extrapolated from other clinical situations where high doses are currently questioned . During AS, the injection of high doses of epinephrine; especially intravenously, is associated with severe complications such as arrhythmia, myocardial infarction and stress cardiomyopathy . Epinephrine should therefore be carefully titrated according to dosing recommendations for AS, to restore adequate circulation and by IM or IV administration as clinically appropriate.…”

Section: Introductionmentioning

confidence: 99%

Treatment with a platelet‐activating factor receptor antagonist improves hemodynamics and reduces epinephrine requirements, in a lethal rodent model of anaphylactic shock

Tacquard

Oulehri

Collange

et al. 2019

Clin Experimental Allergy

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Background In some cases, anaphylactic shock (AS) is still lethal, despite rapid use of epinephrine. High doses of epinephrine are associated with severe complications. Platelet‐activating factor (PAF) is secreted in massive amounts during AS, and a high plasma level is correlated with increased AS severity. Objective To assess the effect of ABT‐491, a PAF‐receptor antagonist and possible adjunct treatment, alone or in combination with epinephrine during AS. Methods AS was induced by intravenous injection of 1 mg ovalbumin into ovalbumin‐sensitized rats. Rats were then randomly assigned to 5 groups (n = 10 per group): SHAM (vehicle only), SHOCK (no treatment), ABT (ABT‐491 1 mg/kg), EPI (epinephrine 5 µg as a bolus then 10 µg kg−1 min−1 by continuous infusion, followed by a reducing protocol) and EPI‐ABT (both treatments). Results Ovalbumin injection resulted in a severe decrease in mean arterial pressure, left ventricular inotropy (max dP/dt) and left ventricular shortening fraction (LVSF). All rats from the ABT group survived until the end of the experiment. ABT‐491 prevented the LVSF decrease observed in the SHOCK group (at T15: ABT 50% ± 11% vs SHOCK 36% ± 9%, P = .01), significantly reduced the dose of epinephrine needed to treat anaphylactic shock (EPI‐ABT 314 ± 67 µg/kg vs EPI 475 ± 69 µg/kg, P < .001) and reduced the time to restore basal MAP (ABT 23 ± 7 minutes vs EPI‐ABT 13 ± 5 minutes, P < .01). Conclusions and Clinical Relevance AS was characterized by early cardiac dysfunction in our model. Treatment with ABT‐491 allowed survival until the end of the experiment and reduced cardiac dysfunction. Use of the PAF‐R antagonist had a synergistic effect with epinephrine and allowed a significant reduction in epinephrine consumption. Use of PAF‐R antagonists during AS could reduce epinephrine‐related complications and improve the treatment of epinephrine refractory cases.

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“…epinephrine is more likely than i.m. to result in cardiac complications in treatment of out-of-hospital anaphylaxis in elderly patients, 31 but there is no previous published information regarding the perioperative setting. The i.v.…”

Section: Epinephrine and Fluidsmentioning

confidence: 99%