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Inadequate anaphylaxis care common in ER.

SAN FRANCISCO -- Fewer than one-quarter of patients with anaphylaxis at a tertiary care hospital received the standard of care, Dr. Yuhung J. Tsai said at the annual meeting of the American Academy of Allergy. Asthma, and Immunology.

Over a 3-year period ending in May 2003, 78 patients with anaphylaxis received treatment in the emergency department, outpatient clinic, or inpatient clinic. Only 17 patients (22%) received a prescription for subcutaneous epinephrine at discharge, and only 19 (24%) received instructions for a follow-up visit with an allergist, Dr. Tsai of St. Joseph Mercy Hospital. Ann Arbor, Mich., reported in a poster presentation.

According to guidelines issued by the Joint Council of Allergy, Asthma, and Immunology, all patients treated for anaphylaxis should receive a prescription for subcutaneous epinephrine and a referral to an allergist. (See box.)

The researchers reviewed medical records retrospectively and used ICD-9 codes to identify anaphylaxis patients; the study included 68 adults and 10 children. The cause of the anaphylaxis was an insect in 37 patients (47%), a medicine or contrast agent in 25 (32%), and a food in 15 (19%). Anaphylaxis resulted from other causes in two patients (3%).

"There is some thought about there being a refractory period after an anaphylactic reaction, particularly a more severe one, where the patient might not be at risk," commented Dr. Richard A. Nicklas, an expert in anaphylaxis at George Washington University Medical Center, Washington. "But I don't think you can assume that," he told this newspaper.

Every patient who has had an anaphylactic reaction should receive some form of injectable epinephrine for use in an emergency. EpiPen, a commercially available epinephrine autoinjector, is fairly easy for patients to use, although Dr. Nicklas declined to endorse a specific product.

Follow-up with an allergist is important as part of the effort "to figure out, if you can, what triggered the reaction so you can take steps to try to avoid it occurring in the future," he added. Guidelines from the Joint Council of Allergy, Asthma, and Immunology recommend a variety of methods for identifying the triggering allergen. In some cases, such as insect bites, the next step is immunotherapy or desensitization.

In a busy emergency department, physicians may not always have the time or the presence of mind to ensure that there's a follow-up visit, he noted. "That's unfortunate, but it doesn't surprise me as much as the fact that a small percentage was given epinephrine in case they need it."

The answer is "education of physicians in general, and particularly of emergency room physicians," Dr. Nicklas said.

RELATED ARTICLE: Patient Education Is Cornerstone of Guidelines for Anaphylaxis Prevention

* Anaphylaxis is a potentially life-threatening condition. Recurrences must be prevented if at all possible.

* Patient education may be the most important preventive strategy. Patients must be carefully instructed about hidden allergens, cross-reactions to allergens, unforeseen risks during medical procedures, and when and how to use self-administered epinephrine, Physicians should educate patients about the risks of future anaphylaxis, as well as the benefits of avoidance measures.

* To maximize the chance of preventing recurrent anaphylaxis, the etiology should be determined and the patient carefully instructed on avoidance, as well as on emergency treatment.

* If future exposure is unavoidable, desensitization or allergen immunotherapy might be considered.

* Cooperative interaction between the primary care provider, clinicians treating anaphylaxis on an emergent basis, and the allergist-immunologist maximizes the likelihood of a successful outcome and prevention of subsequent life-threatening episodes.

Source: The diagnosis and management of anaphylaxis. J. Allergy Clin. Immunol. 101[6 pt. 2]:S465-528, 1998


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Title Annotation:Across Specialties
Author:Finn, Robert
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:May 1, 2004
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