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Recognition and management of anaphylaxis post vaccination

Webinar Series on COVID-19 vaccine: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research (ICR), NIH
Speaker: Dr. Soo Kok Foong, Emergency Medicine Physician in Sungai Buloh Hospital, Ministry of Health Malaysia.

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Recognition and management of anaphylaxis post vaccination

  1. 1. Anaphylaxis Post Vaccination Dr. Soo Kok Foong Emergency Physician Hospital Sungai Buloh
  2. 2. Disclaimers •This slide was prepared for the Webinar Series on COVID-19 session on 3rd March 2021, by Dr Soo Kok Foong, Emergency Physician at the Hospital Sungai Buloh, Malaysia. •This is intended to share within healthcare professionals, not for public. •Kindly acknowledge “Clinical Updates in COVID-19 http://www.nih.gov.my/covid-19” should you plan to share the information obtained from this slide with your colleagues. Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH
  3. 3. Content/Outline •Recognising anaphylaxis •Differential diagnosis •Setting up vaccination centers to prepare for anaphylaxis •Overview of management of anaphylaxis
  4. 4. What is anaphylaxis? WAO 2020: “Anaphylaxis is a serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death. Severe anaphylaxis is characterized by potentially life-threatening compromise in airway, breathing and/or the circulation, and may occur without typical skin features or circulatory shock being present.”
  5. 5. Incidence of post vaccination anaphylaxis Vaccine Hypersensitive data CoronaVac(Sinovac, China) No anaphylaxis events during Phase 3 trials (33,620 participants) BBIBP-CorV (Sinopharm) No anaphylaxis events reported during Phase 3 trials (48,000 participants) Pfizer-BioNTech BNT162b2 No anaphylaxis events attributed to vaccine in clinical trials (~22,000 Participants) Approx. incidence of anaphylaxis 1:100,000 with routine use ChAdOx1 (Oxford/AstraZeneca; Covishield in India) No anaphylaxis events reported in clinical trials (~12,000 Participants) Sputnik V (Gamaleya Research Inst) No events report in Phase 1/2 studies (N=76)
  6. 6. Sign and symptoms Mucocutaneous Eyes: Periorbital swelling. Oral mucosa: Lips, tongue or uvula swelling. Skin: Urticaria, redness, itchiness Cardiovascular syncope, dizziness, tachycardia, hypotension, prolonged CRT, cardiac arrest Respiratory Foreign body sensation, stridor, voice hoarseness, wheezing, breathlessness, chest tightness, coughing, hypoxia Gastrointestinal Severe abdominal cramp Vomiting Diarrhea
  7. 7. Amended diagnostic criteria (WAO 2020) • Stridor • Vocal changes • Odynophagia
  8. 8. Differentiating features of anaphylaxis, vasovagal and panic attack Anaphylaxis Vasovagal reaction Panic attack Onset Usually within 15 minutes of vaccine administration, but can occur within hours Immediate, usually within minutes of, or during, vaccine administration Sudden, occur before, during or after immunization Respiratory Cough, wheeze, hoarseness, stridor, tachypnoea, upper airway swelling (eg lip, tongue, throat, uvula, larynx) Normal Hyperventilate, sensation of breathlessness
  9. 9. Anaphylaxis Vasovagal reaction Panic attack Cardiovascular • Tachycardia • Hypotension (sustained and no improvement without specific treatment) • Hypotension (transient) • Bradycardia (slow, weak but regular) Tachycardia Neurologic Anxiety, distress Faint, light headed Anxiety, lightheaded, dizzy, paresthesias in lips and fingertips Cutaneous • Urticaria, pruritus with or without rash and angioedema (face and tongue) • Warm skin, progressing to clammy and pallor Sweating, clammy skin, pallor Sweating • Gastrointestinal • Abdominal cramps • Diarrhoea • Nausea or vomiting Nausea, vomiting Nausea Abdominal pain
  10. 10. Preparing for anaphylaxis in vaccination center Planning, staff training and education Dedicated observation and treatment area Skilled personnel Emergency medical kit / trolley Written contingency plan Situational awareness Easy access to ambulance Testing the system Preparedness , checklist
  11. 11. Example 1: waiting area 2: screening counter 3: Registration 4: Counselling and consent 5: Vaccination area 6: Chaired observation area 7: bedded observation beds 8: Resuscitation bay
  12. 12. Equipment Medications • Transport Stretcher • Emergency Cart or Bag • Wheelchair • Cardiac monitor or Defibrillator • Oxygen regulator • Portable Oxygen Source • Laryngoscope size 3,4 • Endotracheal tube size 7, 7.5 & 8 • Laryngeal mask airway (LMA) size 3 and 4 • Bag Valve Mask • Medications Chart • Portable Suction • Glucometer • Stethoscope • Large Bore cannula (16G,18G and 20G) • Adrenaline • Normal Saline • Salbutamol • Chlorpheniramine • Hydrocortisone • Ranitidine
  13. 13. PDCA
  14. 14. Overview of anaphylaxis management Acute Management •Get help immediately •Lie supine with leg elevated •IM Adrenaline 0.5mg (0.5ml 1:1000) at anterolateral thigh/ vastus lateralis. Repeat as indicated every 5 minutes up to 3 doses. •100% oxygen supplement •Immediate intubation in impending airway obstruction •Consider nebulised/ MDI salbutamol if persistent bronchospasm Remember: There is NO absolute contraindication for adrenaline in anaphylaxis Prioritise INTRAMUSCULAR adrenaline
  15. 15. If refractory anaphylaxis: •Reassess airway, breathing, circulation •Further IV fluid boluses •IV infusion adrenaline •IV glucagon if patient who is on beta-blocker experiencing refractory anaphylaxis ❑ IV glucagon 1mg-5mg over 5 minutes (slow bolus) followed by IVI glucagon 5mcg-15mcg/min if resistant to adrenaline infusion ❑ Side effect: vomiting
  16. 16. Adrenaline infusion Precaution • Continuous cardiac, HR, Spo2 monitoring. BP every 3-5 minutes. • Initiate by trained personnel or with guidance of specialists. Preparation and dose ❑ Infusion pump is available: • Add 3mg adrenaline (3ml 1:1000) in 47ml of normal saline in a 50ml syringe. • Initial dose can be set at 0.1mcg/kg/min using an infusion pump (eg. in a 50kg patient, to start infusion adrenaline at 5ml/hour). Titrate to effect. ❑ If no infusion pump: • Dilute 0.5mg adrenaline in 500ml normal saline • Run 2ml/minute. Slow increasing it to not more than 10ml/min (titrate to effect) Adjusting adrenaline infusion • Adjust the rate of infusion based on BP, HR and Spo2 • Consider to taper down and cease the infusion if anaphylaxis resolves • Watch out for recurrence after cessation of adrenaline infusion.
  17. 17. Overview management of anaphylaxis
  18. 18. Suggested flow chart of anaphylaxis management out of hospital
  19. 19. Pitfall in anaphylaxis management •Failure to administer adrenaline •Delay in adrenaline due to over reliance on antihistamine and glucocorticoids •Over-reliance on mucocutaneous signs or concepts of more than 2 systems involvement for diagnosis
  20. 20. Take home message •Anaphylaxis is a clinical diagnosis. •IM Adrenaline is the cornerstone treatment •Anticipate the worst, do the best preparation
  21. 21. References • Turner PJ, Worm M, Ansotegui IJ, et al. Time to revisit the definition and clinical criteria for anaphylaxis?. World Allergy Organ J. 2019;12(10):100066. Published 2019 Oct 31. doi:10.1016/j.waojou.2019.100066 • Australian Immunisation Handbook, Department of Health Australia Government • Turner et al. World Allergy Organization Journal (2021) 14:100517 http://doi.org/10.1016/j.waojou.2021.100517 • Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al. World allergy organization anaphylaxis guidance 2020. The World Allergy Organization journal. 2020;13(10):100472. • Rukma P. Glucagon for refractory anaphylaxis. American journal of therapeutics. 2019;26(6):e755-e6. • De Feo G, Parente R, Triggiani M. Pitfalls in anaphylaxis. Current opinion in allergy and clinical immunology. 2018;18(5):382-6.
  22. 22. Email •sookokfoong@gmail.com

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