Download Pre-Learning for Clinical Lab Sciences

Foundations of Interprofessional
Collaboration (FIPC): An Introduction
to TeamSTEPPS®
LEVEL 3
Overview of Clinical Management of
Anaphylaxis for
Clinical Laboratory Science Students
Anaphylaxis Definition
“A serious allergic
reaction that is rapid in
onset and may cause
death.”
National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network
Anaphylaxis Pathogenesis
EXPOSURE
IMMU
NE
REAC
TION
SYMPTOMS
DIAGNOSIS
Acute onset of
illness (minutes
to hours) with:
Identify an Event Lead
(Assigns roles and monitors
situation)
Consider second line
medications:
Assess & Communicate
with Patient
Identify
patient with
possible
anaphylaxis
(Physical exam, keep informed, obtain history,
monitor vital signs & overall status)
Review Patient Chart for
relevant History
•
•
Methylprednisolone 1 mg/kg
H1 antihistamine:
Diphenhydramine 25 mg IV
H2 antihistamines: Cimetidine
4 mg/kg IV
•
(Other possible diagnoses? Possible causes of
anaphylaxis?)
Identify & remove
trigger
Epinephrine 0.3 mg IM
(Can repeat in 5-15 minutes)
Consider alternative
diagnoses and
additional testing
Fluid Bolus
Start Oxygen and
Bronchodilator
(Albuterol 2.5 mg in 3 mL of saline)
(consider confirmatory testing
(tryptase))
Anaphylaxis Practice Parameter; Annals of Allergy Asthma & Immunology; 2015; 115: 341-384.
Inpatient Use of Epinephrine for
Anaphylaxis
• Intramuscular Preferred
– Improved absorption in mid-outer thigh
• Exact dosing for adults and children
– 0.01 mg/kg IM (max dose of 0.5 mg at once)
– Guidelines recommend 0.3 mg IM for adults and reassess
• Caution: Epinephrine dilutions cause of many
medication errors- double check!
– Use 1 mg/ml (or labeled 1:1000) concentration
• Reassess in 5-15 minutes, may repeat if needed
• No Contraindications to Epi in anaphylaxis!
– Monitoring, Drug Interactions, ADRs
Additional Inpatient Medications
for Anaphylaxis
• Bronchodilator
– Albuterol 2.5 mg in 3 mL normal saline
– Nebulized
• Corticosteroids
– Limited evidence to support use but often given to prevent
second phase of anaphylaxis
– Onset 4-6 hours
– Methylprednisolone 1 mg/kg/day IV push
• Antihistamine (H1 and H2 Antagonists)
– Limited evidence to support use but often administered to
treat urticaria
– Diphenhydramine 25 mg IV push
– Cimetidine 4 mg/kg IV infusion or Ranitidine 50 mg IV
push
Potential causes of anaphylaxis
• Allergies to:
– Animal/insect bites or venom
– Latex
– Food
• specifically fish or shellfish, peanuts, etc
– Drugs
Drug-Induced Anaphylaxis
• All medications used immediately
preceding anaphylaxis should be
reviewed!
• Common drugs associated with Type 1
allergic drug reactions include:
– Beta-lactams
– Quinolones
– Neuromuscular blocking agents
– Platinum chemotherapy agents
– Foreign proteins (e.g., rituximab)
Role of the CLS in a Rapid
Response Team
• Gather information about laboratory
testing performed/needs to be ordered
• Provide mutual support to team in
assessing the patient through
documentation.
• Provide laboratory testing
recommendations related to current
assessment and interpretation of current
laboratory results.
Laboratory tests for anaphylaxis
• Tryptase
– While in the testing algorithm for anaphylaxis,
tryptase is a non-specific, confirmatory test.
– It does confirm that an anaphylactic episode has
occurred; however, it is only used if not able to
diagnose via clinical symptomology.
– KUH does about 100/year. Send out testing.
– ~1-2 weeks for results (only done at 2 labs in the US)
• Histamine
– Unreliable – short half-life
– No longer commonly used
Additional anaphylaxis testing
• Specific allergen testing – if patient has no
known allergies
– Skin testing
– IgE assessment
Additional Laboratory concerns
• Patient is a Type 2
Diabetic with a urinary
tract infection.
Concern is that
patient may be septic.
• What tests would you
recommend?
• What tests have been
done? Timing?
• What do they mean?
• Reference ranges?
– Glucose
– HbA1c
– UA/UAM
• Culture and sensitivities
– Blood cultures
• If positive, sensitivities
– Procalcitonin
• Sepsis? Septic Shock?
–
–
–
–
CBC/Diff
Basic Metabolic panel
Hepatic function panel
ammonia