Anaphylaxis Jonathan A. Bernstein, M.D. - PowerPoint Presentation

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Anaphylaxis

Jonathan A. Bernstein, M.D.

Professor of Medicine

Department of Internal Medicine

Division of Immunology/Allergy Section

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Objectives

Definition

Epidemiology

Pathophysiology

Signs + Symptoms

Management

Prevention

JTF Guidelines Algorithms

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Allergy and Clinical Immunology

Asthma/COPD and mimickers

Rhinitis

Recurrent sinusitis

With and without nasal polyps

ImmunodeficiencyUrticaria/angioedemaAtopic dermatitisContact dermatitisPruritusChronic cough

Drug reactions

Food allergy/intolerance

Mast cell disorders

Eosinophilia (PIES, GI disorders, HES…)

Occupational respiratory and skin diseases

Headaches

Insect sting reactions

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Anaphylaxis: No Consensus Definition

Clinical Criteria

Acute onset with skin or

mucosal signs

AND

- Respiratory compromiseOR- Hypotension(Approximately 80% anaphylaxis)

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Anaphylaxis: Definition Continued

Clinical Criteria

Two of the following after

exposure to known allergen

- Skin/mucosal

- Respiratory- Hypotension- GastrointestinalHypotension after exposure to known allergen

Need to use epinephrine?

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Epidemiology

Anaphylaxis

Risk of death

~

1%

Mortality ~ 500 – 1000 deaths annuallyFood (125 – 200 fatalities/year)Insect (40 – 50 fatalities/year)

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Pathophysiology

Hypersensitivity Type I

Prior sensitization

IgE/Mast cell mediated

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Pathophysiology

Histamine

H

1

Smooth muscle contraction, increased vascular permeability, mucus production, coronary artery spasm,

eosinophil+neutrophil chemotaxisH2Increased cardiac contraction, gastric acid secretion, airway mucus production, vascular permeability

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Anaphylaxis Classification

Immunologic (i.e., IgE mediated)

Non-immunologic (

anaphylactoid

)

Idiopathic – diagnosis by exclusion

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Causes: Immunologic

Food

Peanuts + tree nuts

80 – 90 % of food

related

rxn in childrenSeafoodCommon cause in adults

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Causes: Immunologic

Insect

Hymenoptera

Honeybee

Yellow jacket

WaspHornetFire ant

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Causes: Immunologic

Antibiotics

Penicillin

Cross reaction

Cephalosporins

AztreonamCarbapenemsSkin testing

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Causes: Immunologic

Latex – resolved with avoidance measures

Risk factors

Cross reaction

Banana Tomato

Avocado CarrotChestnut CeleryHazel nut PapayaKiwi PotatoMelon

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Other Less Common Immunologic Causes

Progestin Hypersensitivity

Seminal Plasma Hypersensitivity

Alpha Gal Allergy

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Causes: Non-Immunologic

NSAIDs/Aspirin

No cross reaction

Unclear mechanism

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Causes: Non-Immunologic

IV Contrast Media

Risk factors

Asthma

Prior reaction

Premedication(benedryl 50mg po and prednisone 50mg 13, 7 and 1 hour prior to contrast, low osmolality contrast)

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Causes: Non-Immunologic

Exercise

Urticaria/angioedema

Associated factors

Eating before exercise

Specific foods? Celery? atopyProphylaxis not always effectiveCarry Epi and buddy-up

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Causes: Immunologic or Non-Immunologic

Anesthesia

Muscle Relaxants

Induction agents

Opioids

Local anestheticsOther IV agentsColloidsBlood productsProtamine

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Anesthetic Agents Associated With Anaphylaxis

And Proposed Mechanisms

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Skin Testing To Anesthetic Agents

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Clinical Presentation

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Signs and Symptoms of Anaphylaxis

Lieberman P, Nicklas R, Oppenheimer

J, et al. The diagnosis and management of anaphylaxis practice parameter:

2010 update. J Allergy Clin

Immunol

. 2010;126:477e480;

Wood R, Camargo CA, Lieberman P, et al. Anaphylaxis in America: results from a national physician survey.

Ann Allergy Asthma

Immunol

. 2012;109 (

suppl

):A20;

Boyle J, Camargo CA, Lieberman P, et al. Anaphylaxis in America: results from a national telephone survey. J

Allergy Clin

Immunol

. 2012;129 (

suppl

):AB132.

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Essential Features of History in Evaluation of a

Patient Who Experienced Anaphylaxis

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Clinical Presentation

Urticaria

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Clinical Presentation

Angioedema

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Clinical Presentation

GI

Nausea/vomiting

Abdominal pain

CV

Tachycardia – except Bezold-Jarisch reflexHypotensionDysrhythmias

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Clinical Presentation

Respiratory

Rhinitis

Bronchospasm

Laryngeal edema

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Differential Diagnosis of Anaphylaxis

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Diagnostic Tests For Establishing

Anaphylaxis As A Cause

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Diagnostic Testing

Serum

tryptase

level

Peak at 1 – 1 ½ hours,

nl in 6 hoursSerum histamine – not recommended

Elevated at five minutes,

nl

in 30 – 60 minutes

Urinary methylhistamine – 24 hour collection more appropriate for systemic

mastocytosis

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World Health Organization Criteria

For Systemic

Mastocytosis

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Anaphylaxis

Treatment

ABCs

Epinephrine

0.5 mg

IM/SC every 5 minPediatric (0.01 mg/kg, max 0.3 mg)Hypotension 0.01 mg IVCardiovascular collapse 0.1 to 0.5 mg IVInfusion

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Anaphylaxis

Treatment

β

agonists/Oxygen

Corticosteroids – biphasic prophylaxis

1 – 2 mg/kg methylprednisolone IVVolumePositioningAntihistamines H1 – DiphenhydramineH2 – Ranitidine

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Anaphylaxis

Treatment

Dopamine

400 mg in 500 cc D5 at 2-20

ug

/kg/minVasopressinGlucagon1 – 5 mg IV plus infusion 5-15 ug/min

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Anaphylaxis

Disposition

Observation 4 – 6 hours

Risk of Biphasic reaction 4 – 20%

Hospital Admission

Severe or refractory reactionReactive airway diseaseβ blocker

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Anaphylaxis

Treatment on Disposition

Corticosteroids

H

1

BlockerConsider 2nd generation

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Anaphylaxis

Follow-up

Epi-pen

Avoid precipitating allergen

Allergist/PCP

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JTF Guideline:

Algorithm For Initial Evaluation of Anaphylaxis

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Management Of Anaphylaxis In The Outpatient Setting

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References

Sampson HA. Second Symposium on the Definition and Management of Anaphylaxis: Summary Report – Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium.

Ann

Emer

Med

. Vol 47:4 2006Lieberman P. The diagnosis and management of anaphylaxis: An updated practice parameter. J Allergy Clin Immunol. Vol 115:3 2006; Lieberman P et.al. Anaphylaxis--a practice parameter update 2015. Ann Allergy Asthma Immunol. 2015 Nov;115(5):341-84Gruchalla RS,

Pirmohamed

M. Antibiotic allergy.

NEJM

. Vol 354:6 2006

Freeman TM. Hypersensitivity to Hymenoptera Stings.

NEJM

. Vol 351:9 2004

Simons FE. Advances in H1 antihistamines.

NEJM

. Vol 351:21 2004

Simons FE et.al. World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin

Immunol

 2011 Mar;127(3):587-93.

Zibners

L,

Laddis

D,

Sadow

KB. Pediatric anaphylaxis: critical aspects of ED management.

Ped

Emer

Med Reports

. 2006

Mackay IR, Rosen FS. Allergy and allergic disease.

NEJM

. Vol 344:2 2001

Hussain AM Vasopressin for the management of catecholamine-resistant anaphylactic shock.

Singapore Med J

49(9) 2008

Jones DH. Time-dependent inhibition of histamine-induced

cutneous

response by oral and intramuscular diphenhydramine and oral fexofenadine.

Ann Allergy Asthma

Immonol

100(5) 2008

Sheikh A H1-antihistamines for the treatment of anaphylaxis with and without shock.

Cochrane Collaboration

2008

Sheikh A Epinephrine for the treatment of anaphylaxis with and without shock.

Cochrane Collaboration

2008

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Question 1

A 21 year male presents to the ED to with symptoms of diffuse

urticaria

, facial swelling and throat swelling sensation. He relates the symptoms to beginning within 15 minutes after eating at a Chinese restaurant. He has a history of mild allergies and asthma as a child but is otherwise healthy. His vital signs show a blood pressure of 100/60 and a pulse of 95. Physical exam reveals diffuse hives over 85% of his body and upper lip edema. There is no evidence of stridor or posterior pharyngeal swelling on exam

.

Based on this presentation the most appropriate next step is to:

Treat with diphenhydramine 50mg IVP

Treat with

solumedrol

60mg IVP

Treat with epinephrine .05cc 1:1000 IM

Monitor for improvement

Intravenous fluids

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Discussion

Answer – c

Patients presenting to the ED with hives with or without angioedema are often difficult to differentiate from anaphylaxis. Given the acute onset and no prior history in conjunction with the episode occurring in close proximity to eating, it is important to first consider anaphylaxis in this setting. His slightly low blood pressure and elevated pulse could be subtle clues to the occurrence of anaphylaxis. While all of the other answers are appropriately adjunctively, the treatment of choice for this patient should be with epinephrine.

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Question 2

A 54 year old obese male was undergoing radical nephrectomy surgery for renal cell carcinoma. Immediately after induction of anesthesia his blood pressure was noted to decrease to 70/P. There was no evidence of hives or angioedema. He had received cefazolin, lidocaine,

rocuronium

, ketamine, fentanyl and midazolam. He was immediately administered epinephrine and IV fluids. His blood pressure stabilized and the surgery was aborted

.

The most appropriate next step would be:

Administration of diphenhydramine 50mg IV

Obtain blood for a

tryptase

level

Administration of

solucortef

120mg IVP

Skin testing to the anesthetic agents

Refer to a cardiologist for cardiovascular work up

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Discussion

Answer b

This case represents

peri

-operative anaphylaxis which can manifest solely has hypotension without other clinical manifestations. The appropriate treatment was epinephrine and IVFs. While all of the other choices are reasonable to pursue during the hospitalization or as an outpatient, obtaining blood for a

tryptase level would be the best option for determining if the event was indeed anaphylaxis. The earlier blood is drawn after a suspected anaphylaxis event the better chance to observe a positive test as tryptase levels peak within 1-1.5 hours and normalize by 6 hours.