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ANAPHYLAXIS
CHULEEPORN KONGMEESOOK ,MD
Outline
Terminology
Pathophysiology
Signs and symptoms
Prevention and management
Take home messages
Anaphylaxis
Severe, life threatening, generalized
or systemic hypersensitivity reaction.
reaction.

WAO Nomenclature Revie...
Criteria for diagnosing anaphylaxis 1
Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled:...
Criteria for diagnosing anaphylaxis 2
Anaphylaxis is highly likely when any one of the following 3 criteria
are fulfilled:...
Criteria for diagnosing anaphylaxis 3
Anaphylaxis is highly likely when any one of the following 3 criteria
are fulfilled:...
Criteria for diagnosing anaphylaxis 4
Anaphylaxis is highly likely when any one of the following 3 criteria
are fulfilled:...
Incidence of anaphylaxis
No exact incidence.
incidence.
Increased from 0.26 per10,000 persons
per10,
in 1992 to 4.6 per 10...
Incidence of Anaphylaxis to Specific Agents 1
Antibiotics
Most common cause of drug induced
anaphylaxis.
Latex
Increased i...
Incidence of Anaphylaxis to Specific Agents 2
Radiocontrast media
Introduction of lower osmolarity agents
reduced reaction...
Incidence of Anaphylaxis to Specific Agents 3
Food
0.0004% of US population per year.
0004%
Shellfish most common in adult...
Incidence of Anaphylaxis to Specific Agents 4
Perioperative anaphylaxis
Most common agents are muscle relaxants,
which acc...
Incidence of Anaphylaxis to Specific Agents 5
Antisera
Incidence for antilymphocyte globulin as
high as 2% and incidence t...
Factors affecting the incidence
and/or severity of anaphylaxis
Age
Comorbidities
Concurrent medication/chemical use
Other ...
Pathophysiology 1
Anaphylaxis : allergic
IgE mediated
Foods,
Drugs
Insect stings and bites
Exercise (food dependent)
depen...
Pathophysology 2
Anaphylaxis : non-allergic
nonDirect mediator release from mast cells and
basophils
Drugs such as opiates...
Pathophysiology 3
Anaphylaxis : non-allergic
nonDisturbances in arachidonic acid metabolism
Aspirin
Other non-steroidal an...
Nitric oxide
Potentially detrimental
Vasodilation (peripheral vascular bed)
Increased vascular permeability
Potentially be...
Dynamics of cardiovascular abnormality
At onset of
reaction

Blood pressure

↓

Early stage
(minutes)
with no
treatment

P...
Signs and Symptoms of Anaphylaxis 1
Signs and symptoms
Cutaneous

Percentage
>90

Urticaria and angioedema

85-90
85-

Flu...
Signs and Symptoms of Anaphylaxis 2
Biphasic anaphylaxis
Uniphasic anaphylaxis
Protracted anaphylaxis

Lieberman P In: All...
Severity of anaphylaxis reaction
Grade

Skin

GI tract

Res.

CVS

Neuro

1 Mild

Sudden itching
of eyes and
nose,
general...
Differential diagnosis of anaphylaxis 1
Vasodepressor reactions
Flush syndromes
Carcinoid
Menopause
Chlorpropamide–alcohol...
Differential diagnosis of anaphylaxis 2
‘Restaurant syndromes’
Monosodium glutamate (MSG)
Sulfites
Scrombroidosis

Lieberm...
Differential diagnosis of anaphylaxis 3
Excess endogenous production of
histamine syndromes
Systemic mastocytosis
Urticari...
Differential diagnosis of anaphylaxis 4
Other forms of shock
Hemorrhagic
Cardiogenic
Endotoxic
Non-organic disease
Panic a...
Differential diagnosis of anaphylaxis 5
Miscellaneous
Hereditary angioedema
‘Progesterone’ anaphylaxis
Urticarial vasculit...
Laboratory 1
Histamine
Plasma histamine rise within 5- 10 min.
and remain 30-60 min.
30Urinary histamine metabolites eleva...
Laboratory 2
Serum tryptases
Peak 60-90 min.
60Persist longer than plasma histamine
levels but not as long as 5 hours.

Li...
SalaSala-Cunill et al. Int Arch Allergy Immunol 2013;160:192–199
2013;160:192–
SalaSala-Cunill et al. Int Arch Allergy Immunol 2013;160:192–199
2013;160:192–
Medication
Epinephrine
Antihistamines ( H1, H2 )
β-Adrenergic agonist
Glucocorticoid
Volume expanders
Atropine
Glucagon

L...
PhysicianPhysician-Supervised Management of Anaphylaxis 1

I. Immediate Intervention
a) Assessment of airway, breathing,
c...
PhysicianPhysician-Supervised Management of Anaphylaxis 2
II. General measures
a) Place in recumbent position and elevate ...
PhysicianPhysician-Supervised Management of Anaphylaxis 3
III. Specific Measures that Depend on Clinical
Scenario
a) Aqueo...
PhysicianPhysician-Supervised Management of Anaphylaxis 4
III. Specific Measures that Depend on
Clinical Scenario continue...
PhysicianPhysician-Supervised Management of Anaphylaxis 4
III. Specific Measures that Depend on
Clinical Scenario continue...
Clinical practice guidelines for management anaphylaxis

http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf
...
Clinical practice guidelines for management anaphylaxis

Available from :
http://www.allergythai.org/modules/anaphylaxis/C...
Prevention 1
General
Obtain history for drug allergy.
Avoid drugs (immunologic or biochemical
cross-reactivity)
cross-reac...
Prevention 2
For patients at risk
Wear and carry warning identification tags.
Teach self-injection of epinephrine and
self...
Ousama Rachid et al. The Journal of Allergy and Clinical Immunology 2013; 131 : 236-238
236-
Ousama Rachid et al. The Journal of Allergy and Clinical Immunology 2013; 131 : 236-238
2013;
236-
Take Home Message
Anaphylaxis is defined as a serious allergic
reaction.
Prompt recognition and treatment are
critical in ...
THANK YOU
Anaphylaxis
Anaphylaxis
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Anaphylaxis

Presented by Chuleeporn Kongmeesook, MD.

2013

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Transcript of "Anaphylaxis"

  1. 1. ANAPHYLAXIS CHULEEPORN KONGMEESOOK ,MD
  2. 2. Outline Terminology Pathophysiology Signs and symptoms Prevention and management Take home messages
  3. 3. Anaphylaxis Severe, life threatening, generalized or systemic hypersensitivity reaction. reaction. WAO Nomenclature Review Committee JACI 2006
  4. 4. Criteria for diagnosing anaphylaxis 1 Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled: 1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or (eg, flushing, swollen lips-tongue-uvula) lips-tongueAND AT LEAST ONE OF THE FOLLOWING a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) (eg, dyspnea, wheeze-bronchospasm, stridor, b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, end(eg, incontinence) 2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours): a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula) skin(eg, itchlips-tongueb. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) (eg, dyspnea, wheeze-bronchospasm, stridor, c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence) (eg, d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting) (eg, 3. Reduced BP after exposure to known allergen for that patient (minutes to several hours): a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP* b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that person’s baseline Sampson HA et al. J Allergy Clin Immunol 2006; 117:391 - 397 2006; 117:
  5. 5. Criteria for diagnosing anaphylaxis 2 Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled: 1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or (eg, flushing, swollen lips-tongue-uvula) lips-tongueAND AT LEAST ONE OF THE FOLLOWING a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) b. Reduced BP or associated symptoms of end-organ dysfunction (eg, end(eg, hypotonia [collapse], syncope, incontinence) Sampson HA et al. J Allergy Clin Immunol 2006; 117:391 - 397 2006; 117:
  6. 6. Criteria for diagnosing anaphylaxis 3 Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled: 2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours): a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, skin(eg, itchswollen lips-tongue-uvula) lips-tongueb. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia) c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, (eg, incontinence) d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, (eg, vomiting) Sampson HA et al. J Allergy Clin Immunol 2006; 117:391 - 397 2006; 117:
  7. 7. Criteria for diagnosing anaphylaxis 4 Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled: 3. Reduced BP after exposure to known allergen for that patient (minutes to several hours): a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP* b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that person’s baseline PEF, Peak expiratory flow; BP, blood pressure. *Low systolic blood pressure for children is defined as less than 70 mm Hg from 1 month to 1 year, less than (70 mm Hg + [2 x age]) from 1 to 10 years, (70 and less than 90 mm Hg from 11 to 17 years. Sampson HA et al. J Allergy Clin Immunol 2006; 117:391 - 397 2006; 117:
  8. 8. Incidence of anaphylaxis No exact incidence. incidence. Increased from 0.26 per10,000 persons per10, in 1992 to 4.6 per 10,000 persons in 10, 2001. 2001. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027Techapornroong M et al. Asian Pac J Allergy Immunol 2010;28:262-9 2010;28:262-
  9. 9. Incidence of Anaphylaxis to Specific Agents 1 Antibiotics Most common cause of drug induced anaphylaxis. Latex Increased incidence last decade. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  10. 10. Incidence of Anaphylaxis to Specific Agents 2 Radiocontrast media Introduction of lower osmolarity agents reduced reaction rate. Hymenoptera stings Incidence ranges from 0.4-0.8% of children and 3% of adults. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  11. 11. Incidence of Anaphylaxis to Specific Agents 3 Food 0.0004% of US population per year. 0004% Shellfish most common in adults, and peanuts in children. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  12. 12. Incidence of Anaphylaxis to Specific Agents 4 Perioperative anaphylaxis Most common agents are muscle relaxants, which account for 62% of reactions. 62% Non Steroidal Anti-Inflammatory Drugs Anti(NSAIDs) Probably second most common offending drug next to antibiotics. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  13. 13. Incidence of Anaphylaxis to Specific Agents 5 Antisera Incidence for antilymphocyte globulin as high as 2% and incidence to antivenom 4.6-10% 10% Idiopathic Estimated between 20,592 - 47,024 20, 47, cases in USA Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  14. 14. Factors affecting the incidence and/or severity of anaphylaxis Age Comorbidities Concurrent medication/chemical use Other factors Simons FE, JACI 2010;125:161-81 2010;125:161-
  15. 15. Pathophysiology 1 Anaphylaxis : allergic IgE mediated Foods, Drugs Insect stings and bites Exercise (food dependent) dependent) NonNon-IgE mediated Immune aggregates IgG anti-IgA antiCytotoxic Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  16. 16. Pathophysology 2 Anaphylaxis : non-allergic nonDirect mediator release from mast cells and basophils Drugs such as opiates Physical factors : Cold, Sunlight Idiopathic Exercise Activation of contact system Dialysis membranes Radiocontrast media Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  17. 17. Pathophysiology 3 Anaphylaxis : non-allergic nonDisturbances in arachidonic acid metabolism Aspirin Other non-steroidal antiinflammatory drugs nonMultimediator recruitment Complement Clotting Clot lysis Contact system Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  18. 18. Nitric oxide Potentially detrimental Vasodilation (peripheral vascular bed) Increased vascular permeability Potentially beneficial Bronchodilation Vasodilation (coronary arteries) Decreased mast cell degranulation Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  19. 19. Dynamics of cardiovascular abnormality At onset of reaction Blood pressure ↓ Early stage (minutes) with no treatment Prolonged shock ↓↓ ↓↓↓ ↓ ↓↓ →↓ → ↓ Pulse Cardiac output Peripheral vascular resistance ↓ →↓ ↓ ↓↓↓ Intravascular Lieberman In: Allergy: Principles and Practice. Mosby, 2003 volume Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  20. 20. Signs and Symptoms of Anaphylaxis 1 Signs and symptoms Cutaneous Percentage >90 Urticaria and angioedema 85-90 85- Flush 4545-55 Pruritus without rash 2-5 2- Respiratory 40-60 40- Dyspnea, Dyspnea, wheeze 45-50 45- Upper airway angioedema 50-60 50- Rhinitis 1515-20 Dizziness, syncope, hypotension 3030-35 Abdominal Nausea, vomiting, diarrhea, cramping pain 2525-30 Miscellaneous Headache 55-8 Substernal pain 4-6 4- Seizure 11-2 Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  21. 21. Signs and Symptoms of Anaphylaxis 2 Biphasic anaphylaxis Uniphasic anaphylaxis Protracted anaphylaxis Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  22. 22. Severity of anaphylaxis reaction Grade Skin GI tract Res. CVS Neuro 1 Mild Sudden itching of eyes and nose, generalized prurituis, prurituis, flushing, urticaria, urticaria, angioedema, angioedema, Oral pruritus, pruritus, oral tingling, mild lip swelling, nausea or emesis, mild abdominal pain Nasal congestion and/or sneezing, rhinorrhoea, rhinorrhoea, throat pruritis, pruritis, throat tightness, mild wheezing Tachycardia (increase >15 beats/min) Change in activity level plus anxiety 2 Moderate Any of the above Any of the above, crampy abdominal pain, diarrhoea, diarrhoea, recurrent vomiting Any of above, hoarseness,bar ky cough, difficulty swallowing, stridor, stridor, dyspnoea, dyspnoea, moderate wheezing As above Light headedness feeling of pending doom 3 Severe Any of the above, Any of the above loss of bowel control Any of the above, cyanosis or Saturation <92%, respiratory arrest Hypotension* and/or collapse, dysrhythmia, dysrhythmia, severe bradycardia and/or cardiac arrest Confusion, loss of consciousness * Hypotension defined as systolic blood pressure: 1 month to 1 year <70 mmHg; 1–10 years< [70 mmHg + <70 [70 (2 x age)]; 11–17 years <90 mmHg. 11– <90 Muraro et al. Allergy 2007: 62: 857–871 2007: 62: 857–
  23. 23. Differential diagnosis of anaphylaxis 1 Vasodepressor reactions Flush syndromes Carcinoid Menopause Chlorpropamide–alcohol Medullary carcinoma thyroid Autonomic epilepsy Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  24. 24. Differential diagnosis of anaphylaxis 2 ‘Restaurant syndromes’ Monosodium glutamate (MSG) Sulfites Scrombroidosis Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  25. 25. Differential diagnosis of anaphylaxis 3 Excess endogenous production of histamine syndromes Systemic mastocytosis Urticaria pigmentosa Basophilic leukemia Acute promyelocytic leukemia (tretinoin Hydatid cyst treatment) Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  26. 26. Differential diagnosis of anaphylaxis 4 Other forms of shock Hemorrhagic Cardiogenic Endotoxic Non-organic disease Panic attacks Vocal cord dysfunction syndrome Undifferentiated somatoform anaphylaxis Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 1027-
  27. 27. Differential diagnosis of anaphylaxis 5 Miscellaneous Hereditary angioedema ‘Progesterone’ anaphylaxis Urticarial vasculitis Hyperimmunoglobulin E, urticaria syndrome Neurologic (seizure, stroke) Pseudoanaphylaxis Red man syndrome (vancomycin) Capillary leak syndrome Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  28. 28. Laboratory 1 Histamine Plasma histamine rise within 5- 10 min. and remain 30-60 min. 30Urinary histamine metabolites elevated longer period of time. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  29. 29. Laboratory 2 Serum tryptases Peak 60-90 min. 60Persist longer than plasma histamine levels but not as long as 5 hours. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  30. 30. SalaSala-Cunill et al. Int Arch Allergy Immunol 2013;160:192–199 2013;160:192–
  31. 31. SalaSala-Cunill et al. Int Arch Allergy Immunol 2013;160:192–199 2013;160:192–
  32. 32. Medication Epinephrine Antihistamines ( H1, H2 ) β-Adrenergic agonist Glucocorticoid Volume expanders Atropine Glucagon Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  33. 33. PhysicianPhysician-Supervised Management of Anaphylaxis 1 I. Immediate Intervention a) Assessment of airway, breathing, circulation, and mentation. mentation. b) Administer EPI, 1:1000 dilution, 0.3 - 0.5 ml (0.01 mg/kg in children, max 0.3 mg dosage) IM, to control Symptoms and BP Repeat as necessary. Stephen F. Kemp et al.JACI 2002
  34. 34. PhysicianPhysician-Supervised Management of Anaphylaxis 2 II. General measures a) Place in recumbent position and elevate lower extremities. b) Maintain airway c) O2 6 - 8 L/minute. d) NSS IV If severe hypotension, give volume expanders. e) Venous tourniquet above reaction site might decreases absorption of allergen. Stephen F. Kemp et al.JACI 2002
  35. 35. PhysicianPhysician-Supervised Management of Anaphylaxis 3 III. Specific Measures that Depend on Clinical Scenario a) Aqueous EPI 1:1,000, ½ dose (0.1- 0.2 mg) at 000, (0 reaction site. b) Diphenhydramine, 50 mg or more in divided Diphenhydramine, doses orally or IV, maximum daily dose 200 mg (5 mg/kg) for children and 400 mg for adults. c) Ranitidine, 50 mg in adults and 12.5 - 50 mg 12. (1 mg/kg) in children inject IV (Cimetidine 4mg/kg (Cimetidine for adults, not established for pediatrics). Stephen F. Kemp et al.JACI 2002
  36. 36. PhysicianPhysician-Supervised Management of Anaphylaxis 4 III. Specific Measures that Depend on Clinical Scenario continued d) Bronchospasm, nebulized salbutamol Bronchospasm, e) Aminophylline, 5mg/kg over 30 min IV may be Aminophylline, helpful if no response to inhaled β-agonist. βf) Refractory hypotension, give dopamine. Stephen F. Kemp et al.JACI 2002
  37. 37. PhysicianPhysician-Supervised Management of Anaphylaxis 4 III. Specific Measures that Depend on Clinical Scenario continued g) Glucagon, 1- 5 mg (20 - 30 µg/kg [max (20 1 mg] in children) IV h) Methylprednisolone 1- 2 mg/kg/day might prevents prolonged reactions and relapses. Stephen F. Kemp et al.JACI 2002
  38. 38. Clinical practice guidelines for management anaphylaxis http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf
  39. 39. Clinical practice guidelines for management anaphylaxis Available from : http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf http://www.allergythai.org/modules/anaphylaxis/CPG070911full.pdf
  40. 40. Prevention 1 General Obtain history for drug allergy. Avoid drugs (immunologic or biochemical cross-reactivity) cross-reactivity). Orally rather than parenterally. parenterally. Proper labeling. Observe patients 20-30 min. after 20injections. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  41. 41. Prevention 2 For patients at risk Wear and carry warning identification tags. Teach self-injection of epinephrine and selfkeep epinephrine auto-injector. autoDiscontinue β -adrenergic blocking agents, angiotensinangiotensin-converting enzyme (ACE) inhibitors, ACE blockers, monoamine oxidase inhibitors, and certain tricyclic antidepressants. Use preventive techniques. Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1027-49 2009. 1027-
  42. 42. Ousama Rachid et al. The Journal of Allergy and Clinical Immunology 2013; 131 : 236-238 236-
  43. 43. Ousama Rachid et al. The Journal of Allergy and Clinical Immunology 2013; 131 : 236-238 2013; 236-
  44. 44. Take Home Message Anaphylaxis is defined as a serious allergic reaction. Prompt recognition and treatment are critical in anaphylaxis. Epinephrine is the drug of choice for anaphylaxis.
  45. 45. THANK YOU
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