Foundations of Interprofessional Collaboration (FIPC): An Introduction to TeamSTEPPS® LEVEL 3 Overview of Clinical Management of Anaphylaxis for Pharmacy Students

Anaphylaxis Definition “A serious allergic reaction that is rapid in onset and may cause death.” Anaphylaxis is a serious allergic reaction that is rapid in onset and can be fatal. Although it is relatively rare, it can occur anywhere to anyone so we all need to be ready. The good news is that it is usually treatable when it is diagnosed in time. Timely diagnosis can be tricky, though, as the time between exposure and death is usually less than 60 minutes. When patients die from anaphylaxis, it is usually because the treatment, epinephrine, wasn’t given soon enough. National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network

Anaphylaxis Pathogenesis EXPOSURE IMMUNE REACTION Anaphylaxis can be triggered by many types of antigens including foods (such as nuts, shellfish, dairy products, and eggs); medications (from prescription medications, such as antibiotics, as well as over-the-counter medications); venoms (such as from bites and stings); and latex. Adult anaphylaxis most commonly results from medication and venom triggers, whereas children are more likely to experience anaphylaxis due to food allergens. The exposure leads to degranulation of mast cells throughout the body. The products released such as histamine and tryptase lead to symptoms including findings in the skin, such as…, the respiratory tract such as shortness of breath and wheezing, the cardiovascular system, including hypotension and the GI system in the form of N/V/d. SYMPTOMS

DIAGNOSIS Acute onset of illness (minutes to hours) with: The is a WIDE range of patient presentations with anaphylaxis. Most of the time, if you look for Skin/Mucosa findings AND either respiratory or cardiovascular findings, you’ll catch it. The catch is that 20% of the time, there are no skin symptoms and respiratory and CV symptoms are much less common. So, this is a very rare condition that we must always be on the look out for because it can lead to death in minutes. Our patient today with anaphylaxis will have the classic symptoms of skin/mucosa findings and either respiratory or CV symptoms.

Consider second line medications: Identify an Event Lead (Assigns roles and monitors situation) Assess & Communicate with Patient (Physical exam, keep informed, obtain history, monitor vital signs & overall status) Consider second line medications: Methylprednisolone 1 mg/kg H1 antihistamine: Diphenhydramine 25 mg IV H2 antihistamines: Cimetidine 20 mg IV Identify patient with possible anaphylaxis Review Patient Chart for relevant History (Other possible diagnoses? Possible causes of anaphylaxis?) Identify & remove trigger Epinephrine 0.3 mg IM (Can repeat in 5-15 minutes) Once these emergent actions are taken, there are several other components to treatment that may be helpful for your patient. We want to emphasize, that although these may be helpful to the patient over the next few hours, they do not replace and shouldn’t delay the administration of epinephrine. Fluid bolus – start or double check that fluid bolus has been started. 1 L isotonic fluid with a pressure bag. Steroids take 4-6 hrs to work and may be helpful in preventing a second phase of anaphylaxsis hours later. 1-2.0 mg/kg methylprednisonlone) [Of note, There is no strong evidence that supports the use of steroids in the management of anaphylaxis} Inhaled B agonist: Albuterol: 2.5 mg in 3 mL of saline and repeated as necessary Antihistamines help treat symptoms, particularly urticaria. H1 antagonist (diphenhydramine) 25-50 mg IM or slow IV. H2 antihistamines (cimetidine) 4 mg/kg IV. It is important to identify the trigger in order to make sure the exposure is stopped…and also to prevent further exposure. Given the unpredictable ways a patient can present with anaphylaxis, there is ofter uncertainty in diagnosis. Tryptase is one of the mediators released in anaphylaxis and will be elevated for 1-2 hours after the exposure. It takes ~2 weeks to get the result, so doesn’t help with management in the short term, but can be very helpful determining later if in fact the patient did have anaphylaxis and if there were therefore exposures that need to be identified. With animations: So, today, once you identify that your patient likely has anaphylaxis, the goal is to work as a team to stabilize the patient. Since each of the emergent actions needs to happen immediately, we suggest you take a moment to huddle and assign roles. Once these emergent actions are taken, and the patient stabilizes, we suggest you call a second huddle to re-assess patient status and plan the next steps in the treatment. Consider alternative diagnoses and additional testing (consider confirmatory testing (tryptase)) Fluid Bolus Start Oxygen and Bronchodilator (Albuterol 2.5 mg in 3 mL of saline) Anaphylaxis Practice Parameter; Annals of Allergy Asthma & Immunology; 2015; 115: 341-384.

Inpatient Use of Epinephrine for Anaphylaxis Intramuscular Preferred Improved absorption in mid-outer thigh Exact dosing for adults and children 0.01 mg/kg IM (max dose of 0.5 mg at once) Guidelines recommend 0.3 mg IM for adults and re-assess Caution: Epinephrine dilutions cause of many medication errors- double check! Use 1 mg/ml (or labeled 1:1000) concentration Reassess in 5-15 minutes, may repeat if needed Tip: Note time administered and alert when repeat dose could be given if needed No Contraindications to Epi in anaphylaxis! Monitoring, Drug Interactions, ADRs Mechanism of Action: stimulates the alpha, beta-1 and beta-2 receptors (Kinetics: fast onset and fast half-life) Adverse Reactions: cardiovascular (angina, chest pain, hypertension, increased heart rate, arrhythmias, etc.); central nervous (anxiety, dizziness, headache); diaphoresis; tremor, nausea/vomiting Drug Interactions: alpha-blockers and beta-blockers may diminish effects; anti-depressants such as SSRI/SNRI/MAOI/TCA may enhance the vasopressor effect Monitoring: heart rate and blood pressure (will likely increase some after administration, watch for instability or too high of increase)

Additional Inpatient Medications for Anaphylaxis Bronchodilator Albuterol 2.5 mg in 3 mL normal saline Nebulized Corticosteroids Limited evidence to support use but often given to prevent second phase of anaphylaxis Onset 4-6 hours Methylprednisolone 1 mg/kg/day IV push Antihistamine (H1 and H2 Antagonists) Limited evidence to support use but often administered to treat urticaria Diphenhydramine 25 mg IV push Famotidine 20 mg IV push

Drug-Induced Anaphylaxis All medications used immediately preceding anaphylaxis should be reviewed (any medicine could cause it)! Common drugs associated with Type 1 allergic drug reactions include: Beta-lactams Quinolones Neuromuscular blocking agents Platinum chemotherapy agents Foreign proteins (e.g., rituximab)

Role of Pharmacist in Rapid Response Team Collect information (or provide input for team leader) related to medication therapy Assist team in assessing the patient and provide assessments related to medication therapy Provide therapeutic recommendations (e.g., therapy options, dosing, calculations, monitoring) Prepare medications Provide mutual support to other members of the team as needed