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Anaphylaxis Refractory to intra-muscular adrenaline during in-hospital food challenges: a case series and proposed management

Anaphylaxis Refractory to intra-muscular adrenaline during in-hospital food challenges: a case series and proposed management
Anaphylaxis Refractory to intra-muscular adrenaline during in-hospital food challenges: a case series and proposed management

Background: anaphylaxis is a severe, systemic hypersensitivity reaction that can be potentially life-threatening. Anaphylaxis during oral food challenge is not uncommon and can usually be effectively managed with intramuscular adrenaline as first line treatment. Although very rare, fatal anaphylaxis during in-hospital food challenge has been reported.

Objective: we describe our experience of cases of refractory anaphylaxis at in-hospital challenge and propose a framework for escalation of treatment in such cases using intravenous infusion of adrenaline which has been adopted for widespread use elsewhere.

Methods: we present four patients who all experienced severe life-threatening anaphylaxis, refractory to intramuscular adrenaline treatment, during supervised oral food challenges. Patient data were collected from contemporaneous notes, and patient consent was obtained.

Results: in all four cases, the anaphylaxis reactions were amenable to treatment with low-dose intravenous adrenaline, with no reported adverse effects.

Conclusion and clinical relevance: these cases demonstrate the need for clinicians undertaking higher risk allergen challenges to be able to manage cases of severe anaphylaxis refractory to intramuscular adrenaline, and to consider a framework for managing these reactions. While peripheral intravenous adrenaline infusions should always be initiated only in conjunction with expert input, the protocol suggested is simple enough to be undertaken within the hospital environment while more experienced support is obtained.

adrenaline, allergy, anaphylaxis, food allergy, oral food challenge
0954-7894
1400-1405
Alviani, C
32a5985d-da5c-48e4-a098-5374d3546e77
Burrell, S
ea44b9d0-59e0-45ae-a862-6f4e2475a517
Macleod, A
c5f10482-504a-4607-90f4-7ee56b56a0d9
Edees, S
239f03e6-f716-4c0f-84ea-7825cda736c9
Roberts, G
ea00db4e-84e7-4b39-8273-9b71dbd7e2f3
Turner, P J
813ab1ac-8a2f-4d34-a96e-22ebd8e7d40c
Erlewyn-Lajeunesse, M
e1763b6d-165b-45c5-9108-5dc8722220b9
Alviani, C
32a5985d-da5c-48e4-a098-5374d3546e77
Burrell, S
ea44b9d0-59e0-45ae-a862-6f4e2475a517
Macleod, A
c5f10482-504a-4607-90f4-7ee56b56a0d9
Edees, S
239f03e6-f716-4c0f-84ea-7825cda736c9
Roberts, G
ea00db4e-84e7-4b39-8273-9b71dbd7e2f3
Turner, P J
813ab1ac-8a2f-4d34-a96e-22ebd8e7d40c
Erlewyn-Lajeunesse, M
e1763b6d-165b-45c5-9108-5dc8722220b9

Alviani, C, Burrell, S, Macleod, A, Edees, S, Roberts, G, Turner, P J and Erlewyn-Lajeunesse, M (2020) Anaphylaxis Refractory to intra-muscular adrenaline during in-hospital food challenges: a case series and proposed management. Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology, 50 (12), 1400-1405. (doi:10.1111/cea.13749).

Record type: Article

Abstract

Background: anaphylaxis is a severe, systemic hypersensitivity reaction that can be potentially life-threatening. Anaphylaxis during oral food challenge is not uncommon and can usually be effectively managed with intramuscular adrenaline as first line treatment. Although very rare, fatal anaphylaxis during in-hospital food challenge has been reported.

Objective: we describe our experience of cases of refractory anaphylaxis at in-hospital challenge and propose a framework for escalation of treatment in such cases using intravenous infusion of adrenaline which has been adopted for widespread use elsewhere.

Methods: we present four patients who all experienced severe life-threatening anaphylaxis, refractory to intramuscular adrenaline treatment, during supervised oral food challenges. Patient data were collected from contemporaneous notes, and patient consent was obtained.

Results: in all four cases, the anaphylaxis reactions were amenable to treatment with low-dose intravenous adrenaline, with no reported adverse effects.

Conclusion and clinical relevance: these cases demonstrate the need for clinicians undertaking higher risk allergen challenges to be able to manage cases of severe anaphylaxis refractory to intramuscular adrenaline, and to consider a framework for managing these reactions. While peripheral intravenous adrenaline infusions should always be initiated only in conjunction with expert input, the protocol suggested is simple enough to be undertaken within the hospital environment while more experienced support is obtained.

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e-pub ahead of print date: 30 September 2020
Published date: December 2020
Additional Information: © 2020 The Authors. Clinical & Experimental Allergy published by John Wiley & Sons Ltd.
Keywords: adrenaline, allergy, anaphylaxis, food allergy, oral food challenge

Identifiers

Local EPrints ID: 444747
URI: http://eprints.soton.ac.uk/id/eprint/444747
ISSN: 0954-7894
PURE UUID: 36719248-22f4-44f8-a4c6-950d7a40d52a
ORCID for G Roberts: ORCID iD orcid.org/0000-0003-2252-1248
ORCID for M Erlewyn-Lajeunesse: ORCID iD orcid.org/0000-0003-1982-1397

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Date deposited: 03 Nov 2020 17:30
Last modified: 28 Apr 2022 02:24

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Contributors

Author: C Alviani
Author: S Burrell
Author: A Macleod
Author: S Edees
Author: G Roberts ORCID iD
Author: P J Turner
Author: M Erlewyn-Lajeunesse ORCID iD

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