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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