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Emphasizing, reassessing epinephrine use improves outcomes
A clinical pathway that emphasized early epinephrine use and reassessed its use before IV placement improved outcomes in pediatric patients with allergy, according to findings presented at the American College of Allergy, Asthma and Immunology Annual Scientific Meeting.
“Emergency department management of anaphylaxis has not kept pace with advances in knowledge. Epinephrine use and utilization of guideline-based practice recommendations remains suboptimal, particularly in children,” researchers wrote.
They utilized a pathway that highlighted early epinephrine use and re-evaluated its use prior to IV placement on 936 patients in a pediatric ED.
Researchers found that when comparing patient outcomes 3 years before and 10 months after first using the pathway, the mean time to epinephrine for Emergency Severity Index 1 patients dropped from 11.3 minutes to 4.3 minutes. The proportion of patients with anaphylaxis receiving ED IV placement dropped from 40.7% to 19.9%. In addition, the incidence of using a less-sedating H1 blocker in combination with an H2 blocker escalated from 15.8% to 52.8% when an H1 antihistamine was used. However, the proportion of patients admitted to the hospital and mean length of ED stay for discharged patients with anaphylaxis did not change.
Researchers wrote a future analysis will seek shortening ED observation periods to lessen the time low-risk patients spend in the hospital. – by Janel Miller
Reference: Brown J, et al. Improving emergency care for anaphylaxis: Impact of a clinical pathway in a pediatric emergency department. Presented at: American College of Allergy, Asthma and Immunology Annual Scientific Meeting; Nov. 15-19, 2018; Seattle.
Disclosures: Please see the meeting’s abstract book for the authors’ relevant financial disclosures.
Perspective
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As an allergist, one of my most important tasks is counseling patients and families on how to treat in the event of anaphylaxis, an acute, life threatening allergic reaction. I spend a lot of time in the office reviewing the signs and symptoms of anaphylaxis, when and how to use an epinephrine auto-injector, and how to access emergency medical care. Early treatment with epinephrine can prevent fatality from anaphylaxis and may also decrease the risk of being hospitalized or having anaphylaxis symptoms recur in the hours following treatment (biphasic anaphylaxis). But even with this extensive discussion and encouragement, I know that many of my patients and families will hesitate to use intramuscular epinephrine due to fear or uncertainty. One of the challenges is that this reaction is rapid, unpredictable and will most likely occur out of the allergy office. My patients and I rely on the providers of emergency medical care to support them during a reaction.
Because of this, it has been concerning that studies have shown that anaphylaxis is underrecognized and epinephrine is underutilized in a variety of medical settings outside of an allergist’s office. I have been focused in my research in changing practices in the pre-hospital setting and Brown and colleagues take a multidisciplinary and comprehensive approach to dealing with anaphylaxis in the emergency department. The multidisciplinary focus is particularly valuable. Because of the rapidly progressing nature of anaphylaxis, it is important for all levels of medical professionals to recognize anaphylaxis and understand the importance of early treatment with epinephrine.
The clinical pathway developed by Brown and colleagues prioritizes first-line administration of intramuscular epinephrine in a visible and consistent way. It also does a nice job of addressing recognition of anaphylaxis by developing a scoring system to be used by providers and having signs and symptoms of anaphylaxis prominently and repeatedly present in the pathway. With use of this pathway, time to epinephrine decreased, placement of an IV decreased and use of less sedating antihistamines increased compared to more sedating antihistamines. Studies like this one reinforce how changes in established practices in medicine can be achieved with comprehensive approaches. Widespread adoption of similar multidisciplinary pathways in emergency departments to improve awareness of anaphylaxis and the importance of first-line treatment with intramuscular epinephrine could improve care and outcomes of many patients with anaphylaxis.