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OJHAS Vol. 7, Issue 4: (2008
Oct-Dec) |
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Treatment of Anaphylaxis in Adults: A Questionnaire Survey |
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Shalini Adiga,
Associate Professor,
Dept of Pharmacology, Kasturba Medical College, Manipal,
Veena Nayak,
Assistant Professor,
Dept of Pharmacology, Kasturba Medical College, Manipal
K.L Bairy
Professor, Dept of Pharmacology, Kasturba Medical College, Manipal |
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Address For Correspondence |
Associate Professor,
Dept of Pharmacology,
Kasturba Medical College, Manipal,
Karnataka, INDIA
E-mail:
drshali2000@yahoo.co.in |
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Adiga S, Nayak V, Bairy KL. Treatment of Anaphylaxis in Adults: A Questionnaire Survey Online J Health Allied Scs.
2008;7(4):6 |
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Submitted: Nov 20, 2008; Accepted:
Jan 15, 2009 Published: Feb 25, 2009 |
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| Abstract: |
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Objective:
To identify the medications that medical students, interns and casualty
medical officers are likely to prescribe when treating an adult patient
with anaphylaxis, and to ascertain the dose and route of administration
of adrenaline they would use. Design: A questionnaire
study survey. Setting: Kasturba
medical college hospital, Manipal (Udupi District) and public health
centers of Udupi district, Karnataka. Subjects: Data
collected from 39 second year medical students, 35 interns and 35 casualty
medical officers. Main outcome
measure: To determine the percentage of use of adrenaline for the treatment
of anaphylaxis in the correct dose, strength and route. Results: Majority
(73 .3%) of participants correctly opted to use adrenaline. Only 9 participants
have written the correct dose, route and concentration of adrenaline.
41.28% and 66.05% participants preferred to use antihistamines and corticosteroids
respectively. Conclusion: This study has shown that confusion
exists regarding the correct route of administration and dose of adrenaline to
be used when treating anaphylaxis. This confusion applied to medical students,
interns and medical officers. Therefore doctors must be made aware of the
guidelines to treat anaphylaxis effectively.
Key Words:
Anaphylaxis, Adrenaline |
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Anaphylaxis
is a life threatening systemic allergic condition. It is charecterised
mainly by hypotension, bronchospasm and angioedema of lips and mucous
membrane. Anaphylaxis is a type I reaction caused by release of mediators
from mast cells and basophils following binding with IgE. The term anaphylactoid
reaction refers to a non IgE mediated mast cell or basophil activation.
The most common trigger factors are food substances like peanuts, milk,
shellfish, drugs like penicillins, cephalosporins, radiocontrast media
or idiopathic.
Adrenaline
is the life saving drug for anaphylaxis. But, it is also dangerous as
it can cause cardiac arrhythmias and myocardial ischemia. Oxygen, antihistamines,
corticosteroids, nebulised β2-agonists, IV fluids may also
be indicated.(1) Previous studies have shown that there
exists confusion in the treatment of this emergency condition.(2-4)
Hence it is essential that doctors working in the emergency department
should be aware of the correct drug, route and dose of adrenaline.
Since junior
doctors, also can be called upon to treat this emergency condition we
planned to conduct this study in interns working at Kasturba Medical
College Hospital, Manipal and also in casualty medical officers ( CMO)
working at public health centres in Udupi district, who are the first
medical responders. We also included the medical students
who are being taught on this subject during second year of medical curriculum.
The aim of this study was to identify the medications that medical students,
interns and casualty medical officers are likely to prescribe when treating
an adult patient with anaphylaxis, and to ascertain the dose and route
of administration of adrenaline they would use. The use of antihistamines
and corticosteroids were also studied.
Second year
medical students (n=39), interns (n=35) and casualty medical officers
(n=35) were asked to answer a questionnaire under supervision which
contained two hypothetical adult cases of anaphylaxis. The questionnaire
used in a previous study (2) was modified and used in the
present study. The identity of the participants
was not revealed. However, they were asked to fill in their designation.
There was no compulsion to partake and subjects were informed that they
were participating in a study.
A total of
109 questionnaires were collected. 80 (73.3%) participants correctly
opted to use adrenaline. 84.61% of second year students, 74.28% of interns
and 60% of medical officers opted for adrenaline. The percentage of
participants in each group opting for the different routes of adrenaline
is given in the Table 1. But 10.3% of students, 25.7% of interns and
40% of medical officers preferred hydrocortisone and 5.1% of students
preferred salbutamol inhaler. The percentage of participants in each
group preferring the different concentrations of adrenaline is given
in Table 2. Only 9 students have written the correct dose (0.5mg), route
(IM) and concentration (1:1000). However 13 participants (8 students,
3 interns and 2 medical officers) did not know the dose of adrenaline
though they knew the correct concentration of adrenaline as 1:1000.
Two medical officers have preferred IV route (1ml) of 1:10000 dilution.
One and eight participants have proposed to give a higher dose of adrenaline
in 1:10000 and 1:1000 dilutions respectively.
Regarding the
time for the next dose, 43.11% of the participants (14 medical students,
18 interns and 15 medical officers) have correctly said that the next
dose of adrenaline can be given as early as 5 minutes. But ten participants
did not know when to give the second dose and 17 participants proposed
not to give a second dose of adrenaline. The preferences opted by the
individual groups regarding the time for next dose is given in Table
3. As an answer to the question regarding second line drugs for anaphylaxis,
41.28% and 66.05% participants preferred to use antihistamines and corticosteroids
respectively. The preferences for other second line treatments preferred
by the participants are given in Table 4. The participants were ignorant
of any existing guidelines for the management of anaphylaxis.
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Table 1:
Percentage of participants opting for different routes of adrenaline |
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Group number |
Group |
Adrenaline
All routes/doses |
Adrenaline IM |
Adrenaline 1:1000
IM - correct
dose
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Adrenaline IV |
Adrenaline SC |
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1 |
Medical students (39) |
33 (84.61%) |
20 (51.3%) |
9 (45%) |
11 (28.2%) |
2 (5.1%) |
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2 |
Interns (35) |
26( 74.28%) |
9 (25.7%) |
0 (0%) |
11 ( 31.4%) |
6 (17.1%) |
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3 |
CMO (35) |
21 (60%) |
1 (2.9%) |
0(0%) |
7 ( 20%) |
13 (37.1%) |
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4 |
Total (109) |
80 (73.3%) |
30 (27.5%) |
9 ( 9%) |
29 (26.6%) |
21 (19.3%) |
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Table 2:
Percentage of participants opting for different dilutions of adrenaline |
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Group
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1:100 |
1:1000 |
1:10000 |
1:100000 |
1:200000 |
Don’t know |
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Medical students |
1(2.56%) |
24(61.5%) |
6(15.4%) |
- |
1(2.56%) |
7(19.4%) |
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Interns |
- |
8(22.85%) |
20(57.14%) |
3(8.57%) |
1(2.85%) |
3 (8.57%) |
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CMO |
- |
10(28.57%) |
18(51.42%) |
1(2.85%) |
- |
6(17.14%) |
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| Table 3:
Timing opted for the second dose of adrenaline by the participants |
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Group |
Don’t know |
1min |
5min |
15min |
Any other |
No second dose |
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Medical students
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6 (15.38%) |
1(2.56%) |
14 (35.89%) |
10(25.64%) |
0 (0%) |
8 (20.51%) |
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Interns
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2(5.71%) |
7(20%) |
18(51.42%) |
7(20%) |
0 |
1(2.85%) |
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CMO |
2(5.71%) |
8(22.85%) |
15(42.85%) |
1(2.85%) |
1(2.85%) |
8(22.85%) |
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Table 4:
Second line treatments preferred by the participants |
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Group |
NSAIDS |
Diuretics |
IV fluids |
Oxygen |
Nebulisation |
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Medical students
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2 |
2 |
3 |
0 |
0 |
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Interns
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0 |
2 |
0 |
0 |
0 |
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CMO |
0 |
1 |
7 |
3 |
3 |
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Total
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2(1.8%) |
5(4.6%) |
10(9.2%) |
3(2.8%) |
3(2.8%) |
The main aim of this study was to identify the medications that doctors
would administer when treating an adult patient with anaphylaxis and
to ascertain the routes and doses of adrenaline that they would use.
The first problem describes a patient with anaphylaxis for which 73.3%
of participants in this study stated that they would give adrenaline
as their first line of treatment. The other 26.7% would give either
IV hydrocortisone, or nebulised salbutamol. Although these are useful
in the treatment of anaphylaxis, adrenaline is the life saving drug
in anaphylaxis as it acts on α, β1, β2, all
of which are required to reverse the pathophysiologic processes of anaphylaxis.
(5) This study has shown that confusion exists regarding the correct
route of administration and dose of adrenaline to be used when treating
anaphylaxis. This confusion applied to medical students, interns and
medical officers. In this study, 26.6% and 19.3% of participants chose
to give adrenaline by IV route and subcutaneous routes respectively.
The absorption of adrenaline is unpredictable when given by subcutaneous
route as the blood flow to the skin would be decreased in anaphylactic
shock. . Adrenaline by IM route should be used as first line treatment
in the majority of situations to treat anaphylaxis. Injection in the
anterolateral aspect of thigh may lead to more predictable and rapid
absorption of adrenaline. (6)
Previous studies have shown that plasma
levels are higher when given by intramuscular route than when given
by subcutaneous route
and also it avoids the potentially lethal effects of large IV bolus
injections. In some patients with impaired cardiovascular function,
intravenous injection of epinephrine may be required. Adrenaline should
be given intravenously only during cardiac arrest or to profoundly hypotensive
patients who have failed to respond to multiple injections of epinephrine
and IV fluid replacement. Intravenous adrenaline should be administered
by experienced clinicians and requires constant monitoring. (7)
This study
has shown that many doctors are unaware of the correct dose of adrenaline
to use when treating anaphylaxis. In response to Question 2, only 9
medical students (9% of all participants) who chose the IM route, and
2 medical officers (1.83% of total) opting for the IV route actually
knew the correct dose.
Surprisingly,
13 participants did not know the correct dose of adrenaline though they
knew the correct concentration of adrenaline and 9 participants have
written higher dose of adrenaline. 8 participants have asserted that
the second dose of adrenaline cannot be given. However 40% to 70% of
patients with severe anaphylaxis will require more than one dose of
adrenaline. The dose of adrenaline can be repeated every 5-15 minutes.(6) The findings of this study highlight the need to educate
clinical staff regarding the correct dose, route and concentration of
adrenaline to be used in anaphylaxis.
Antihistamines
(H1- and H2-receptor antagonists) such as diphenhydramine
(25–50 mg orally, intramuscularly, or intravenously every 4–6 hours)
and ranitidine (150 mg orally every 12 hours or 50 mg intramuscularly
or intravenously every 6–8 hours) may be useful adjuvant therapies
for alleviating the cutaneous manifestations of urticaria or angioedema
and pruritus and for the gastrointestinal and uterine smooth muscle
spasms. Inhalation of selective adrenergic agonists such as albuterol,
and intravenous administration of aminophylline (0.5 mg/kg/h IV with
6 mg/kg loading dose over 30 minutes) for bronchospasm and corticosteroids
may reduce prolonged reactions or relapses. [6] In this study
most of the participants preferred to use corticosteroids and antihistamines
as second line drugs. Very few participants have preferred to use oxygen,
salbutamol nebulisation and IV fluids. Diuretics and nonsteroidal anti-inflammatory
drugs have no role in the treatment of anaphylaxis.
This survey reflects the knowledge of students and doctors who may be
called upon to treat patients with anaphylaxis. The lifetime risk of
anaphylaxis is presumed to be 1% to 3% per individual with mortality
rate of 1 %. (7) Therefore, all doctors should be able to
diagnose anaphylaxis and treat it effectively. There are resuscitation
guidelines put forward by various countries for the management of anaphylaxis
that are found to be almost similar.(3-4) The same needs
to be implemented by our doctors for an effective treatment of anaphylaxis
Our sincere acknowledgements are due to all the participants of the
study.
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Treatment of anaphylaxis in adults: results of a survey of doctors at Dunedin
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MM. Proposed use of adrenaline
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Med J 2002;78:416–418.
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Ricardo
J, Gerald JC. Survey of the use of epinephrine (adrenaline) for anaphylaxis
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Hoffman
BB. Adrenoceptor-activating and other sympathomimetic drugs, In: Katzung
BG, Basic and clinical pharmacology.10th edition, Singapore:
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Kishiyama
JL, Adelman DC. Allergic and immunologic disorders, In: McPhee SJ, Papadakis
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