Page 1810 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 128: Anaphylactic and Anaphylactoid Reactions 1279

Inhaled β -Adrenergic Agonists: An inhaled β agonist can be help- in its prevention. In addition, at this time, the only available route of
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ful, especially when bronchospasm does not respond to epinephrine. administration is oral and therefore the onset of action of such agents
There is anecdotal evidence that inhaled epinephrine can be effective in in anaphylaxis would not be optimal. 20
anaphylaxis. Tranexamic acid: It has been used to treat anaphylactic episodes associ-
Vasopressors: There are no prospective studies comparing different ated with disseminated intravascular coagulation; however, it is not
vasopressor agents in the management of refractory anaphylactic available in the United States. 118
shock. Even in the hands of intensive care specialists, use of intrave- Nitric oxide inhibitor: NO synthesis inhibition via methylene blue
nous vasopressors might not improve outcomes and might increase has been reported, in case reports, to be helpful in the treatment of
fatality rates. 159,160 Both dopamine and norepinephrine have been used hypotension occurring during anaphylaxis. There are no controlled
as vasopressor agents. A recent large randomized study compared the studies, however, involving the use of this agent in anaphylaxis. 176
use of dopamine and norepinephrine in the treatment of shock. The
study found no difference in mortality but a greater number of adverse
effects in the group treated with dopamine. Unfortunately the number of
patients with anaphylactic shock in this study was minuscule. There is KEY REFERENCES
161
one report evaluating the effectiveness of vasopressin on hypotension in • Chung CH, Mirakhur B, Chan E, et al. Cetuximab-induced ana-
two adults who experienced insect sting anaphylaxis and one report of phylaxis and IgE specific for galactose-alpha-1,3-galactose. N Engl
a patient who received vasopressin after anaphylaxis to a drug. 162,163 No J Med. March 13, 2008;358(11):1109-1117.
controlled studies have been performed to evaluate the potential efficacy
of vasopressin in anaphylaxis, alone or in combination with epinephrine. • Finkelman FD. Anaphylaxis: lessons from mouse models. J Allergy
Clin Immunol. September 2007;120(3):506-515; quiz 516-517.
Corticosteroids: Steroids are often recommended for use in the man- • Fleming JT, Clark S, Camargo CA et al. Early treatment of
agement of patients experiencing anaphylaxis. However, the evidence food-induced anaphylaxis with epinephrine is associated with a
in support of the use of steroids is unclear. A recent Cochrane review lower risk of hospitalization. The J of Allergy and Clin Immunol.
concluded that there is no evidence from high-quality studies for the Available online September 8, 2014.
use of steroids in the emergency management of anaphylaxis and it • Hamilton RG, Adkinson NF Jr. 23. Clinical laboratory assess-
neither supported nor refuted the use of these drugs for this purpose. ment of IgE-dependent hypersensitivity. J Allergy Clin Immunol.
164
Glucocorticosteroids have not been shown to be effective for the acute February 2003;111(2 suppl):S687-S701.
treatment of anaphylaxis but could, theoretically, prevent protracted
anaphylaxis. There is no conclusive evidence that the administration • Lieberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma
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of corticosteroids prevents a biphasic response. 165 Immunol. September 2005;95(3):217-226; quiz 226, 258.
• Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis
β-Blockers and Anaphylaxis: Patients with anaphylactic reactions who are and management of anaphylaxis practice parameter: 2010 update.
on β-blockers are likely to experience severe anaphylactic reactions char- J Allergy Clin Immunol. September 2010;126(3):477-480.
acterized by paradoxical bradycardia, profound hypotension, and severe • Limb SL, Starke PR, Lee CE, Chowdhury BA. Delayed onset and
bronchospasm. There are no epidemiologic studies that indicate that ana- protracted progression of anaphylaxis after omalizumab adminis-
phylaxis occurs more frequently in patients receiving β-blockers. The tration in patients with asthma. J Allergy Clin Immunol. December
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risk is not reduced in patients who are using selective β blockers because 2007;120(6):1378-1381.
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both β - and β -antagonists may inhibit the β-adrenergic receptor.
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These systemic effects have also been documented with the use of topi- • Sampson HA, Munoz-Furlong A, Campbell RL, et al. Second sym-
cal ophthalmic β-blockers. Greater severity of anaphylaxis observed in posium on the definition and management of anaphylaxis: sum-
166
patients receiving β-blockers might relate, in part, to a blunted response mary report—Second National Institute of Allergy and Infectious
to endogenously produced epinephrine as well as the administration of Disease/Food Allergy and Anaphylaxis Network symposium.
this drug to treat anaphylaxis. Epinephrine administered to a patient J Allergy Clin Immunol. February 2006;117(2):391-397.
166
taking a β-blocker can produce unopposed α-adrenergic and reflex • Schwartz LB. Diagnostic value of tryptase in anaphylaxis and
vagotonic effects, possibly leading to hypertension and the risk of cere- mastocytosis. Immunol Allergy Clin North Am. August 2006;26(3):
bral hemorrhage. Patients on β-blockers are at increased propensity 451-463.
167
not only for bronchospasm, but also decreased cardiac contractility with • Simons E. Anaphylaxis. J Allergy Clin Immunol. 2010;125:s161-s181.
perpetuation of hypotension and bradycardia. 167-169 For these reasons, • Simons FE. Anaphylaxis: recent advances in assessment and treat-
β-blocker–related anaphylaxis may be more likely to be refractory to ment. J Allergy Clin Immunol. October 2009;124(4):625-636; quiz
management. Glucagon and very aggressive fluid (up to 7 L of crystalloid) 637-638.
resuscitation may be necessary if epinephrine is ineffective in treating
anaphylaxis in patients taking β-blockers. 170-175 Glucagon may reverse • Simons FE, Frew AJ, Ansotegui IJ, et al. Risk assessment in ana-
refractory bronchospasm and hypotension during anaphylaxis in patients phylaxis: current and future approaches. J Allergy Clin Immunol.
on β-blockers by activating adenyl cyclase directly and bypassing the July 2007;120(1 suppl):S2-S24.
β-adrenergic receptor. 170-173 The recommended dosage for glucagon is • Stone SF, Cotterell C, Isbister GK, Holdgate A, Brown SG. Elevated
1 to 5 mg (20-30 mg/kg [max 1 mg] in children) administered intrave- serum cytokines during human anaphylaxis: identification of
nously over 5 min and followed by an infusion, 5 to 15 mg/min, titrated potential mediators of acute allergic reactions. J Allergy Clin
to clinical response. Protection of the airway is important since glucagon Immunol. October 2009;124(4):786-792. e784.
may cause emesis and risk of aspiration in severely drowsy or obtunded • Vadas P, Gold M, Perelman B, et al. Platelet-activating factor, PAF
patients. Placement in the lateral recumbent position may be sufficient acetylhydrolase, and severe anaphylaxis. N Engl J Med. January 3,
airway protection for many of these patients. 2008;358(1):28-35.

OTHER PROPOSED THERAPIES FOR ANAPHYLAXIS
Several other therapeutic agents have been proposed for use in anaphylaxis.
REFERENCES
Leukotriene inhibitors: At this time, there are no data documenting the
efficacy of leukotriene inhibitors in the treatment of anaphylaxis or Complete references available online at www.mhprofessional.com/hall

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