Epinephrine and its use in anaphylaxis: Current issues
Faculty of Pharmacy and Department of Pediatrics & Child Health, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. Current Opinion in Allergy and Clinical Immunology
(Impact Factor: 3.57).
08/2010; 10(4):354-61. DOI: 10.1097/ACI.0b013e32833bc670
Epinephrine is a life-saving medication in the treatment of anaphylaxis, in which it has multiple beneficial pharmacologic effects. Here, we examine the evidence base for its primary role in the treatment of anaphylaxis episodes in community settings.
We review the practical pharmacology of epinephrine in anaphylaxis, its intrinsic limitations, and the pros and cons of different routes of administration. We provide a new perspective on the adverse effects of epinephrine, including its cardiac effects. We describe the evidence base for the use of epinephrine in anaphylaxis. We discuss the role of epinephrine auto-injectors for treatment of anaphylaxis in community settings, including identification of patients who need an auto-injector prescription, current use of auto-injectors, and advances in auto-injector design. We list reasons why physicians fail to prescribe epinephrine auto-injectors for patients with anaphylaxis, and reasons why patients fail to self-inject epinephrine in anaphylaxis. We emphasize the primary role of epinephrine in the context of emergency preparedness for anaphylaxis in the community.
Epinephrine is the medication of choice in the first-aid treatment of anaphylaxis in the community. For ethical reasons, it is not possible to conduct randomized, placebo-controlled trials of epinephrine in anaphylaxis; however, continued efforts are needed towards improving the evidence base for epinephrine injection in this potentially fatal disease.
Available from: Sandra M Salter
- "While we recognise the importance of an holistic approach in autoinjector device training, pharmacists are a sound option for training in the periods when physician review is not possible. Patients may wait months after diagnosis for an appointment with their allergy specialist, or only see their general practitioner when a new prescription is required to replace an expired device (every 1–2 years)
. Consultations may be time-restricted and patients may be overwhelmed with new information, reducing the potential for a memorable device demonstration by physicians. "
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Successful treatment of anaphylaxis in the community relies on early and correct use of epinephrine autoinjectors. Community pharmacists supply these devices and have a crucial role teaching patients how to use them. Supply of epinephrine autoinjectors in Australia increased 70-fold in the past decade. New EpiPen and Anapen autoinjectors were launched in Australia in 2011 and 2012, with the potential to cause confusion. However there is no information about how pharmacists demonstrate epinephrine autoinjectors to patients. Therefore the aim of this study was to assess real-world community pharmacist demonstrations of EpiPen and Anapen. We also sought to identify consultation-based predictors of accurate demonstration.
Demonstration accuracy was assessed in simulated patient visits to 300 randomly selected pharmacies. Pharmacists were asked by the simulated patient how to use original EpiPen, new-look EpiPen or Anapen, and assessed against the relevant Australasian Society of Clinical Immunology and Allergy (ASCIA) Action Plan for Anaphylaxis. Other anaphylaxis advice provided by the pharmacist was also recorded. Accuracy was analysed descriptively. Binary logistic regression was used to identify predictors of accurate demonstration.
All 300 pharmacies were visited. Of 250 pharmacist demonstrations, 46 (18.4%) accurately demonstrated all four steps on ASCIA Action Plan. Failure to state ‘do not touch the needle’ (74.8%) or ‘massage injection site’ (68.8%) reduced accuracy. However 163 (65.2%) accurately demonstrated the three steps required to inject epinephrine (no difference by device, p = 0.15). Associations with accurate demonstration were: checking if the patient had an anaphylaxis action plan (odds ratio, OR = 16.1; 95% CI: 3.86-67.3); stating to call an ambulance after use (OR = 4.0; 95% CI: 1.44-11.1); or explaining side effects of epinephrine (OR = 4.5; 95% CI: 1.48-13.4).
It is critical that anaphylaxis patients know how to use their prescribed epinephrine autoinjector correctly. Pharmacists have acceptable rates of EpiPen and Anapen demonstration accuracy, although more is needed to improve this. Those who pay attention to the need for action plans, emergency care after epinephrine use, and informing patients about the side effects of epinephrine may have better knowledge about anaphylaxis, and in turn significantly improve demonstration accuracy.
Available from: Bart Van Goethem
- "These include airway management, oxygen supplementation, fluid therapy, discontinuation of anesthesia and immediate medical therapy (Girard and Leece, 2010). Epinephrine is considered the drug of choice in anaphylactic shock, and can best be administered in dogs as an IV CRI of 0.05 µg/kg/minute (Mink et al., 2004;Sampson et al., 2006;Girard and Leece, 2010;Simons and Simons, 2010). Epinephrine activates both α and β-receptors, resulting in increased systemic vascular resistance and a subsequent increase in blood pressure (α 1 -receptor activation), an increase in cardiac output, myocardial oxygen consumption, coronary artery dilatation (β 1 -receptor stimulation), bronchodilation, decreased peripheral vascular resistance , decreased release of inflammatory mediators from mast cells and basophils and relief of urticaria (β 2 -receptor stimulation) (Peck et al., 2008a;Simons et al., 2011). "
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ABSTRACT: In this case series, the occurrence and successful treatment of anaphylaxis after the intravenous administration of amoxicillin/clavulanic acid are described in two dogs under general anesthesia. Within five to ten minutes after the administration of the antibiotic, a severe hypotension occurred in both dogs, accompanied by labial and periorbital swelling and erythema. Therapy consisted of counteracting the cardiovascular effects of anaphylaxis and preventing further release of inflammatory mediators. Both dogs recovered uneventfully from the drugrelated anaphylaxis.
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ABSTRACT: In ultrasonic diffraction tomography, ultrasonic waves are used to
probe the object of interest at various angles. The incident waves
scatter when encountering inhomogeneities, and thus do not travel in
straight lines through the imaged object. When the scattering
inhomogeneities are considered weak, the scattering object can be
reconstructed by algorithms developed from a generalized central slice
theorem. In this work, the authors develop a hybrid algorithm for
reconstruction of a scattering object by transforming the measured
scattered data into a conventional X-ray-like sinogram thus allowing
standard X-ray reconstruction algorithms, such as filtered
back-projection, to be applied. The authors systematically investigate
and compare the statistical properties of three different algorithms: a
direct Fourier inversion algorithm, the filtered back-propagation
algorithm (which is analogous to the conventional filtered
back-projection algorithm), and the newly developed hybrid algorithm.
The authors derive analytical expressions for the variance of the noise
in the reconstructed images and investigate the noise properties of the
algorithms by performing extensive numerical simulations
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