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2. food allergies

Anaphylaxis Management Guidelines
Contents
Page
Introduction
2-5
References
6-7
Anaphylaxis during Anaesthesia: Diagnostic Card
8
Anaphylaxis during Anaesthesia: Immediate Management
9
Anaphylaxis during Anaesthesia: Refractory Management
10
Anaphylaxis during Anaesthesia: Post Crisis Management
11
ANZAAG-ANZCA Anaphylaxis Management Guidelines: Introduction Version 1.1 June 2013
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Introduction
ANAPHYLAXIS IS A LIFE THREATENING EMERGENCY
1. Prompt recognition of signs and symptoms is crucial
2. Adrenaline administered early and in adequate doses is the
mainstream of treatment of anaphylaxis
3. Aggressive volume replacement is essential
Currently there are no randomised controlled trials of sufficient quality on the management of
anaphylaxis on which to base evidence based guidelines1,2. This document and anaphylaxis
management cards are based upon a review of the literature focusing on guidelines for
management of anaesthetic anaphylaxis 3,4,5,6 as well as general guidelines for the management
of anaphylaxis1,7,8,9. The following recommendations are consensus statements by the Australian
and New Zealand Anaesthetic Allergy Group (ANZAAG) aimed at optimising the management of
perioperative anaphylaxis by anaesthetists.
A prime objective of ANZAAG was to present management guidelines in a format applicable to
crisis management in the perioperative setting. There are 4 management cards that should be
placed in the clinical environment where they are most readily accessed (e.g. on cardiac arrest
trolley). They are: 1) Diagnostic Card 2) Immediate Management 3) Refractory Management and
4) Post Crisis Management. All four cards have different designs reflecting their different contexts
of use.
By keeping the cards generic and simple the hope is that they will be useful when this rare, but
potentially life-threatening crisis occurs. Cognitive aids are of little use unless they become part of
crisis training ideally with someone delegated to read out loud the steps on the card10,11. The
introduction of the cards into a clinical area should include an orientation to their use. This would
also provide an opportunity to revise current local management protocols for anaphylaxis.
Anaphylaxis during Anaesthesia - Diagnostic Card
Early recognition and prompt management of anaphylaxis is essential1,2. The diagnostic card
outlines the classification of severity of anaphylaxis in accordance with the physical signs
present4. In addition to use with the other management cards, the design of this card makes it
suitable for display as a poster in clinical areas. Anaphylaxis should be considered if skin signs
co-exist with bronchospasm or hypotension. Hypotension or tachycardia alone, especially where
this is unresponsive to vasopressors or unexpected for the stage of operation, should cause
anaphylaxis to be considered. Bronchospasm or difficulty with ventilation may be the sole
presenting feature in some cases. The absence of skin signs does not rule out the diagnosis of
anaphylaxis, as skin signs may not appear until circulation is restored4. It is particularly important
to take mast cell tryptase levels in cases where the diagnosis is unclear to help differentiate
anaphylaxis from other causes of perioperative adverse reaction4.
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Anaphylaxis during Anaesthesia - Immediate Management
The card for immediate management has been designed to be used during a crisis. The main
points of managing a crisis are listed down the left-hand side, whereas the right-hand side gives
more detailed instructions.
It is suggested that the card be read out by another member of the team and actions confirmed
with the team leader, who is usually the most senior anaesthetist or primary anaesthetist at the
time of the event. The use of a ‘designated reader’ has been shown to improve the effectiveness
of teams in crises11.
Adrenaline (Evidence Category Level IV)1,2,13,14
Adrenaline is pivotal in the management of anaphylaxis because of its unique pharmacology. In
the doses recommended adrenaline causes vasoconstriction, bronchodilation, increased cardiac
output, reduced mucosal oedema, and reduced mediator release. Therefore adrenaline not only
treats symptoms but also reduces response amplification1,2.
Dosing regimens for adrenaline vary from country to country, partly because of adrenaline’s
narrow therapeutic window. For some patients the risks of overdose are higher e.g. extremes of
age, patients with hypertension, ischaemic heart disease or hyperthyroidism. In others there will
be decreased effectiveness of both endogenous and exogenous catecholamines e.g. β-blockers,
angiotensin converting enzyme inhibitors (ACEI). Cocaine and amphetamines in contrast will
sensitise the myocardium to the effects of adrenaline. Despite this, the best available evidence is
that adrenaline is key to the management of anaphylaxis. Clinicians need to be aware of the
potential for toxicity including accidental overdose, particularly during crisis management13.
The World Allergy Organisation has pointed out that in reviewing fatalities from anaphylaxis
adrenaline administration was often delayed or inadequate9,15. Diagnosis must therefore be rapid
and adrenaline must be administered early and in adequate doses to optimise outcome.
Although the focus of these crisis management cards is on moderate to severe anaphylaxis, mild
anaphylaxis (Grade I) must also be recognised and treated with sufficient adrenaline to correct
physiological parameters and prevent further mediator release. Doses of adrenaline may be
intravenous (in the presence of close haemodynamic monitoring) and should initially start small
(5-10mcg in an adult, 0.1-0.2 mcg/kg in children) and be titrated to effect, escalating if necessary.
Intramuscular adrenaline (anterolateral thigh, 300-500mcg of 1:1000) is likely to be a safer option
in these cases1,2,9. World Allergy Organisation guidelines state that benefits of IM adrenaline for
the management of anaphylaxis far exceed the risks (Evidence Category IV)1,2. Mild anaphylaxis
can result in poor outcomes when it is either under-treated or treated with excessive adrenaline
doses12.
Intramuscular (IM) adrenaline should be considered in the initial management of perioperative
anaphylaxis where IV access is not yet established or is lost, or where haemodynamic monitoring
is not insitu with the start of the reaction. The mainstay of the management of anaphylaxis during
anaesthesia is carefully titrated IV adrenaline with close monitoring of haemodynamic and
physiologic response. A requirement for repeated boluses via either the IV or IM route should
prompt the anaesthetist to establish an adrenaline infusion as early as possible4,16,17.
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The ANZAAG guidelines recommend the initial use of intravenous (IV) bolus adrenaline in
keeping with other international perioperative anaphylaxis management guidelines3,4,5. These
recommendations are only intended for use during anaesthesia with an anaesthetist in
attendance. They reflect the special circumstances of operative anaphylaxis - continuous
dedicated monitoring by an anaesthetist and a higher frequency of sudden onset severe
symptoms compared to non-operative anaphylaxis. For non-anaesthetic anaphylaxis the
guidelines entitled “Anaphylaxis: Emergency Management for Health Professionals” should be
applied7.
Fluid Resuscitation (Level IV Evidence16,18)
Along with adrenaline therapy this is a critical step in management of hypotension. It has been
shown that up to 35% to 70% of the blood volume may extravasate in 10 -15 minutes16,18,19. This
requires aggressive management and repeated fluid boluses of 20mls/kg may be required.
Colloid or crystalloid may be used. Colloid may be more effective during anaphylaxis to restore
intravascular volume4. The exception to this would be where a colloid was running at the time of
the reaction. In this case the colloid is a potential culprit and administration should cease.
Triggers
Muscle relaxants are the most common trigger of anaphylaxis during anaesthesia in
Australasia20,4. Antibiotics are also common triggers. Anaphylaxis to chlorhexidine is an
emerging concern and further use of this agent should be avoided if it was administered prior to
the development of symptoms21. Chlorhexidine may be present in products including skin
preparations and wipes, lubricant gels (e.g. urinary catheters) and impregnated central venous
lines. The anaesthetist needs to be aware that these products are sometimes poorly labelled and
the number of products containing chlorhexidine is increasing. Similarly, latex, dyes and colloids
utilised prior to the reaction may be overlooked as triggers. It is important to consider all possible
antigens and cease further administration, especially in cases of refractory anaphylaxis.
Maintenance of Anaesthesia
Anaesthesia should be maintained with minimal volatile agent until the situation is stabilised. A
depth of anaesthesia monitor (eg. BIS) is advisable.
Monitoring
Standard monitoring as recommended by the Australian and New Zealand College of
Anaesthetists (ANZCA)22 should be utilised throughout resuscitative efforts. An arterial line is
highly recommended where possible to aid cardiovascular monitoring, blood sampling and
continuous monitoring of adrenaline effects.
Intravenous Access
Large bore intravenous access and/or a central venous catheter (CVC) should be secured as
soon as possible. If chlorhexidine has been a possible trigger of the reaction, the anaesthetist is
advised to avoid placement of a chlorhexidine impregnated central line or use of chlorhexidine
skin preparation.
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Position
Patients should be returned to the supine position as soon as possible where continued
resuscitative efforts are required. Where hypotension is persistent leg elevation should be
considered (Level IV evidence4,9,23). Pregnant patients must be placed with left tilt to reduce
vena caval compression and optimise venous return.29
Temperature Maintenance
All staff managing anaphylaxis must be aware of the importance of minimising patient exposure
during resuscitative efforts. Hypothermia has the potential to worsen outcome with increased risk
of arrhythmia, cardiac ischemia and coagulopathy.
Anaphylaxis During Anaesthesia - Refractory Management
It is suggested the card for refractory anaphylaxis be used as a team checklist, similar to a
surgical time-out. A single ‘reader’ of the card calls out the items in turn and team members
ensure that all potential omissions and further management points have been completed to
maximise the chances of a positive patient outcome.
The immediate management of anaphylaxis necessitates titration of adrenaline, adequate fluid
replacement and optimising oxygenation. In some situations these measures, including a
maximal adrenaline infusion, may not be adequate. This is known to occur in patients on ßblockers, ACEI and with spinal blockade. In this scenario, all maximal initial measures must be
continued and specific targeted therapy added in accordance with symptoms and local availability
of medications.
Particular issues with anaphylaxis during anaesthesia in the pregnant patient include positioning
in left lateral position or left tilt to minimise vena caval compression, and facilitation of delivery
where relevant29.
Other Vasopressors
The evidence for use of other vasopressors is based on use in animal models and some case
reports of improved clinical parameters in refractory anaphylaxis4,24. Recommendations for their
use are thus weaker than adrenaline and they should only be used following the adequate
administration of adrenaline. Their role is likely to be more important when high infusion rates of
adrenaline and fluid boluses are inadequate to maintain an appropriate perfusion pressure.
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Anaphylaxis During Anaesthesia - Post Crisis Management
Steroids
There is no evidence that steroids change outcome in anaphylaxis4,25. However, they have been
of benefit in the management of other allergic diseases. As such they are recommended as part
of secondary management i.e. only for administration after all acute management has been
completed and the patient is stable. They may be useful in cases where there is a protracted
reaction or biphasic response.
Antihistamines
Antihistamines do not have a role in the acute phase of anaphylaxis crisis management in the
operating theatre7,26. Accordingly, ANZAAG has removed the use of antihistamines from the
acute anaphylaxis management guidelines. These drugs are useful for the symptomatic
treatment of urticaria, angioedema and pruritus. They have little effect on hypotension and
bronchospasm7,26. They may be used for mild allergic reactions involving skin signs only. Oral
antihistamines such as cetirizine have a better side-effect profile compared to parenteral
promethazine. Injectable promethazine should not be used in anaphylaxis as it can worsen
hypotension and cause muscle necrosis.
Serum Tryptase Levels
Elevated total serum tryptase level is supportive of the diagnosis of perioperative anaphylaxis27.
The peak level is usually reached 15-120 minutes after onset of the reaction. The tryptase level
declines slowly within the following 3-6 hours. The biological half-life for tryptase is approximately
two hours. The return to baseline level can generally be verified 24 hours after the reaction28. On
this basis, the guidelines recommend timing for the sampling of tryptase to detect the peak level
and also the recovery to normal baseline. Care must be taken to send the specimens
immediately after collection to the laboratory for urgent processing to ensure accurate results.
References
1.
Simons FE et al. World Allergy Organisation Guidelines for the Assessment and
Management of Anaphylaxis. WAO Journal 2011; 4: 13-37
2.
Aziz Sheikh, Yasser A Shehata, Simon GA Brown, F Estelle R Simons. Adrenaline for the
treatment of anaphylaxis with and without shock. The Cochrane Library 2010; 10: 1-17
3.
Association Anaesthetists of Great Britain and Ireland. Suspected anaphylactic reaction
associated with anaesthesia. Anaesthesia 2009; 64: 199-211
4.
Mertes PM, Malinovsky JM, Jouffrou L et al. Reducing the risk of anaphylaxis during
anesthesia: 2011 updated for clinical practice. J Investig Allergol Clin Immunol 2011; 21:442-453
5.
Kroigaard M et al. Scandinavian Clinical Practice Guidelines on Diagnosis, Management
and Follow up of Anaphylaxis during Anaesthesia. Acta Anaesthesiol Scand 2007; 51: 655-70
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6.
Rose M, Fisher M. Anaphylaxis and Anaesthesia. What can we do better? Australasian
Anaesthesia 2009: 115-119
7.
Australasian Society of Clinical Immunology and Allergy. Anaphylaxis:
Management for Health Professionals (poster). Aust Prescr 2011;34:124
Emergency
8.
Sampson HA et al. 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. J Allergy Clin Immunol 2006; 117: 391-397
9.
Brown SGA, Mullins RJ, Gold MS. Anaphylaxis: diagnosis and management. MJA 2006;
185:283-289
10.
Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids in a simulated
anesthetic crisis. Anesth Analg. 2006 Sep;103(3):551-6
11.
Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a
"reader?" improvement of rare event management with a cognitive aid "reader" during a
simulated emergency: a pilot study. Simul Healthc. 2012 Feb;7(1):1-9
12.
Pumphrey RS. Lessons for the management of anaphylaxis from a study of fatal reactions.
Clin Exp Allergy 2000; 30:1144-50
13.
Kemp SF et al. Epinephrine: the drug of choice for anaphylaxis. A statement of the World
Allergy Organisation. Allergy 2008; 63: 1061-1070
14.
McLean-Tooke APC, Bethune CA, Fay AC, Spickett GP. Adrenaline in the treatment of
anaphylaxis: what is the evidence? BMJ 2003;327 1332-1335
15.
Garvey LH, Belhage B, Kroigaard M. Treatment with Epinephrine (Adrenaline) in
Suspected Anaphylaxis during anaesthesia in Denmark. Anesthesiology 2011;115: 111-6
16.
Brown SGA, Blackman KE, Stenlake V, Heddle RJ. Insect sting anaphylaxis; prospective
evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J
2004; 21 149-154
17.
Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M. Part 12: Cardiac arrest in special
situations:2010 American Heart Association guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2010; 122:S829-861
18.
Clarke R, Sadleir PHM, Van Niekerk AW, Platt P. Quantification of volume loss and
haemodynamic changes of Gelofusine®-induced anaphylaxis during cardiopulmonary bypass.
Anaesth Intensive Care 2011; 39: 492-495
19.
Fisher MM. Clinical observations on the pathophysiology and treatment of anaphylactic
cardiovascular collapse. Anesth Intensive Care 1986; 14:17-21
20.
McNeill O, Kerridge RK, Boyle MJ. Review of procedures for investigation of anaesthesiaassociated anaphylaxis in Newcastle, Australia. Anaesth Intensive Care 2008 Mar;36(2):201-7
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21.
Jee R, Nel L, Gnanakumaran G, Williams A, Eren E. Four cases of anaphylaxis to
chlorhexidine impregnated central venous catheters: a case cluster or the tip of the iceberg? Br J
Anaesth. 2009 Oct;103(4):614-5
22.
ANZCA Professional Standards. PS 18 Recommendations on Monitoring during
Anaesthesia,
2008.
www.anzca.edu.au/resources/professionaldocuments/documents/professional-standards/professional-standards-18.html.
23.
Pumphrey RSH. Fatal posture in anaphylactic shock. J Allergy Clin Immunol
2003;112;451-452
24.
Schummer C, Wirsing M, Schummer W. The pivotal role of vasopressin in refractory
anaphylactic shock. Anesth Analg 2008; 107 :620-624
25.
Choo KJL, Simons E, Sheikh A. Glucocorticoids for the treatment of anaphylaxis:
Cochrane systemic review. Allergy 2010; 65 1205-1211
26.
Sheikh A, Ten Broek V, Brown SG, Simons FE. H1-antihistamines for the treatment of
anaphylaxis: Cochrane systematic review. Allergy 207;62:830-837
27.
Ebo DG, Fisher MM, Hagendorens MM, Bridts CH, Stevens WJ. Anaphylaxis during
anaesthesia: diagnostic approach. Allergy 2007;62:471-487
28.
Schwartz LB. Diagnostic Value of Tryptase in Anaphylaxis and Mastocytosis. Immunol
Allergy Clin N Am 2006;26:451-463.
29.
Simons FER, Schatz, M. Anaphylaxis during pregnancy. J Allergy Clin Immunol 2012;
597-605
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