Emergency Anaphylaxis Management: Opportunities for Improvement. Ronna Campbell, MD, PhD August 31, 2015

Transcription

1 Emergency Anaphylaxis Management: Opportunities for Improvement Ronna Campbell, MD, PhD August 31, 2015

2 disclosures Anaphylaxis Roundtable discussion held at the 2014 American College of Allergy, Asthma and Immunology Annual Meeting

3 Increased Anaphylaxis Hospitalizations in the US J Allergy Clin Immunol 2014;133:

4 National Study of US ED Visits for Allergic Reactions, million allergy-related ED visits during study period ( ) 1% of all ED visits Rate remained stable over study period 4% required hospitalization Only 1% were coded as anaphylaxis 50% of patients coded as anaphylaxis received epinephrine Ann Allergy Asthma Immunol. 2007;98:

5 Multicenter Study of ED Visits for Food Allergy The Multicenter Airway Research Collaboration performed a chart review study in 21 North American EDs over 1 Year (1999) ED Management 72% of patients received antihistamines 48% received systemic corticosteroids 33% received respiratory treatments 16% received epinephrine Among patients with severe reactions (55% of total), 24% received epinephrine 97% of patients were discharged to home 16% prescribed self-injectable epinephrine 12% referred to an allergist

6 Anaphylaxis and EMS Allergic reactions/anaphylaxis make up % of EMS transports Variable rates of EMS Epinephrine administration (14-36%) Not all states require ambulances to be equipped with epinephrine Not all levels of EMTs are authorized to administer epinephrine for anaphylaxis (EMTs and Epinephrine.

7 2010 Systematic Review- Physician Gaps in Anaphylaxis Management Allergy 2010; 65:

8 Opportunities for Improvement Improve recognition and diagnosis of anaphylaxis Increase epinephrine administration for anaphylaxis or severe allergic reactions Increase SIE prescribing, Action Plan use and allergy/immunologist follow up after an ED/urgent care visit Promote continued collaboration between EM physicians and Allergy/Immunologists

9 Improve recognition and diagnosis of anaphylaxis

10 Undercoding or underrecongnition of anaphylaxis Among all ED allergy related diagnoses, only 1% were coded as anaphylaxis. Detailed analysis of food-induced allergic reactions demonstrated that 51% were actually anaphylaxis. Detailed analysis of insect sting allergy found that 31% of were actually anaphylaxis. Ann Allergy Asthma Immunol. 2007;98: J Allergy Clin Immunol. 2004;113: J Allergy Clin Immunol. 2005;116:

11 2 ND Symposium on the Diagnosis and management of anaphylaxis July 2005 Multidisciplinary Multinational NIAID/FAAN Criteria proposed J Allergy Clin Immunol 2006;117:391-7.

12 1 Acute onset of an illness (minutes to several hours) with involvement of : 2 After exposure to likely allergen, symptoms involving 2 or more of the following organ systems: 3 After exposure to known allergen: Anaphylaxis is likely when any one of the 3 criteria are fulfilled: SKIN & MUCOSA Itching Flushing Hives Angioedema AND EITHER RESPIRATORY Dyspnea Wheeze Stridor PEF Hypoxemia SKIN & MUCOSA Itching Flushing Hives Angioedema RESPIRATORY Dyspnea Wheeze Stridor PEF Hypoxemia BP BP OR END ORGAN DYSFUNCTION OR BP OR END ORGAN DYSFUNCTION Collapse Syncope Incontinence Collapse Syncope Incontinence GASTROINTESTINAL Abdominal Pain Vomiting Diarrhea J Allergy Clin Immunol 2006;117:391-7.

13 Test Characteristics of NIAID/FAAN Criteria in ED Sensitivity 97% Specificity 82% PPV 69% NPV 98% This means that 69% of patients who meet NIAID/FAAN criteria will have anaphylaxis and 98% of patients who don t meet NIAID/FAAN criteria will not have anaphylaxis. J Allergy Clin Immunol 2012;129:

14 Increase epinephrine administration for anaphylaxis or severe allergic reactions

15 A Patient does not need to have anaphylaxis to need epinephrine Severe allergic reactions (not meeting criteria for anaphylaxis) Patients who may progress to a more severe allergic reaction

16 EPInephrine is safe There are no absolute contraindications to epinephrine use. Epinephrine is safe when administered appropriately.

17 Epinephrine Administration IM Dosing 0.01 mg/kg IM (max of 0.5 mg=0.5 ml of 1:1000) Autoinjector Dosing 0.15 mg (15-30 kg) 0.3 mg (>30 kg) IV Bolus Dosing (for impending cardiovascular collapse when infusion is not available) Cautiously consider-50 microgram bolus of 1:10,000 (0.5 ml) (this is 1/10 of the IM max dose) Guidelines differ IV infusion Dosing 1 microgram/min to max of 10 micrograms/min (ADULTS) 0.1 micrograms/kg/min starting dose (PEDS)

18 ACLS EpiNephrine 1 mg (10 ml) (1:10,000) IV/IO push

19 Iatrogenic EpiNephrine OverdoseS 4 cases of severe cardiovascular complications with IV epinephrine overdose for suspected anaphylaxis over 5 years in one ED (Ann Emerg Med. 2010;55: ) 5/12 (42%) patients treated with IV epinephrine for IV contrast reactions received excessive epinephrine doses (3-0.5 mg, 2-1mg) (AJR Am J Roentgenol Aug;191(2):409-15) UK study of 164 cases of fatal anaphylaxis found that 4 fatalities were due to epinephrine overdose (Pumphrey RSH. Clin Exp Allergy, 2000)

20 Iatrogenic epinephrine overdoses in one ED 23 yo F with respiratory distress after eating seafood received 2 doses of 1 mg (1:10,000) epinephrine IV push per physicianwritten order. developed severe (but reversible) cardiomyopathy (EF 15%). 52 yo F with shortness of breath and throat constriction after ingestion of catfish. 0.3-mg 1:1,000 was ordered, route was not specified in the written order. Nurse delivered it IV CP/ST elevation, negative cardiac cath. 33 yo F received 0.3 mg IV rather than IM as it was ordered severe chest pain, ECG changes, coronary artery dissection. 34 yo F with anaphylaxis after seafood ingestion received the cardiac arrest dose of 1 mg (1:10,000) IV push (instead of 0.1 mg (1:10,000) slow IV due to confusion between verbal and written order Ventricular tachycardia

21 Fatal Epinephrine overdoses in the UK 13 yo F with mild allergic symptoms 3.5 mg IV Epi Bolus Fatal Pulm Edema 63 yo F IV abx allergic rxn 2.5 mg IV Epi Bolus Fatal Pulm Edema 38 yo F mild sx from nut allergy 1 mg IV epi Bolus vomiting aspiration arrest 26 yo M mild allergic reaction 1 mg IM epi MI arrest Pumphrey RSH. Clin Exp Allergy, 2000.

22 High risk of OD and CV complications with IV Bolus Epinephrine Adverse CV events were associated with 3 of 30 doses of IV bolus epinephrine compared with 4 of 316 doses of IM epinephrine (10% vs 1.3%; OR 8.7, P =.006). Overdose occurred with 4 of 30 doses of IV bolus epinephrine compared with 0 of 316 doses of IM epinephrine (13.3% vs 0%; OR 61, P <.001). J Allergy Clin Immunol Pract Jan-Feb;3(1):76-80.

23 Safer Epinephrine Administration 1 out of 7 hospitals in upper Michigan surveyed carried prefilled syringes for IM administration in their crash carts Autoinjectors mitigate risk of overdose Ann Emerg Med. 2010;55:

24 Increased ED Epinephrine administration after Introduction of Epinephrine Autoinjectors and anaphylaxis order set Evaluated anaphylaxis management before and after implementation of an ED anaphylaxis order set and introduction of epinephrine autoinjectors Patients who presented after order set implementation were more likely to be treated with epinephrine (51% vs 33%; OR 2.05) J Allergy Clin Immunol Pract May-Jun; 2(3):294-9.

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26 Better than before 37/61 (77%) anaphylaxis patients received epinephrine either before ED arrival or in the ED 39% received epinephrine in the ED 2 A/I specialists reviewed appropriateness of epinephrine administration 60/61 (98%) anaphylaxis patients treated appropriately in the ED

27 Increase rates of SIE prescribing, Action plan use And Allergy/immunologist Follow up

28 After the ED visit Several studies have demonstrated low rates of SIE prescribing and A/I follow up for ED anaphylaxis patients. Further studies are needed to understand barriers to providing SIE prescriptions and ensuring A/I follow up. Do EM providers understand importance of A/I follow up increase follow up rates? Do patients understand importance of follow up? Do primary care providers refer patients to A/I? Are there enough A/I specialists to meet patient needs? Would order set implementation be helpful? Automated follow up phone call from an A/I provider or nurse after an ED visit?

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30 Importance of A/I follow up after ED anaphylaxis visit 573 ED anaphylaxis patients 217 A/I follow up (38%) 77 patients (35%) had an alteration in the diagnosis of anaphylaxis or trigger after A/I evaluation Four patients (2%) were diagnosed with a mast cell activation disorder 13 patients (6%) underwent immunotherapy or desensitization J Allergy Clin Immunol Pract Jan-Feb;3(1):88-93.

31 Action Plan FARE/ACEP 2014

32 Promote continued collaboration between em Physicians and A/I specialists Second symposium on the Diagnosis and Management of Anaphylaxis (2005) Anaphylaxis Toolkit: Starter Guide for Newly Diagnosed Patients. Food Allergy Research and Education (2014) Emergency department diagnosis and treatment of anaphylaxis: a practice parameter (2014) Addressing barriers to emergency anaphylaxis care: from emergency medical services to emergency department to outpatient follow-up (2015)

33 Conclusions Continued use of NIAID/FAAN criteria to increase anaphylaxis recognition Promote autoinjector access in ED to decease risk of iatrogenic OD Increase awareness/use of Action Plans Understand and address barriers to SIE prescribing and A/I follow up Continue AI/EM/EMS collaboration

34 Thank you QUESTions

35 Fatal Anaphylaxis in the US

36 Non-fatal overdose 3/175 patients receiving epinephrine for suspected allergic reactions received 1 mg IV epinephrine 35 yo F with panic attack-> homonymous hemianopsia 42 yo M local swelling from sting ->palpitations, headache, syncope ->full recovery 45 yo F sting -> stroke with persistent left sided weakness