1. IN THE NAME OF GOD

2. Anaphylaxis Dr.h-kayalha Anesthesiologist

3. Definition of Anaphylaxis Systemic allergic reaction –Affects body as a whole –Multiple organ systems may be involved Onset generally acute Manifestations vary from mild to fatal

4. Antigen to Antibody Relationship Antigen the foreign protein that when taken into the body stimulates/formulates specific protective proteins called antibodies. Antibody a protein produced in the body to response to a specific antigen (foreign protein) to destroy or inactivate the antigen. (IgE)

5. Histamine Coronary vasoconstriction Bronchoconstriction Vascular permeability Intestinal smooth muscle contraction Dysrhythmias: sinus tach, a-fib, ….

6. Pathogenesis of Anaphylaxis IgE-mediated (Type I hypersensitivity) Sensitization stage Subsequent anaphylactic response

7. Sensitization Stage  Antigen (allergen) exposure  Plasma cells produce IgE antibodies against the allergen  IgE antibodies attach to mast cells and basophils Mast cell with fixed IgE antibodies IgE Granules containing histamine Antigen Plasma cell

8. Anaphylactic Reaction  More of same allergen invades body Antigen Mast cell granules release contents after antigen binds with IgE antibodies Histamine and other mediators.  Allergen combines with IgE attached to mast cells and basophils, which triggers degranulation and release of histamine and other chemical mediators

9. Common Causes of IgE-mediated Anaphylaxis Foods Insect venoms Latex Medications Immunotherapy –Insect venom –Inhalant allergens

10. Anaphylactoid Reactions Non–IgE-mediated –Complement-mediated Anaphylatoxins, egg, blood products –Direct stimulation egg, radiocontrast media –Mechanism unknown Exercise NSAIDs

11. Clinical Manifestations of Anaphylaxis Skin: Flushing, pruritus, urticaria, angioedema Upper respiratory: Congestion, rhinorrhea Lower respiratory: Bronchospasm, throat or chest tightness, hoarseness, wheezing, shortness of breath, cough

12. Clinical Manifestations of Anaphylaxis Gastrointestinal tract: –Oral pruritus –Cramps, nausea, vomiting, diarrhea Cardiovascular system: –Tachycardia, bradycardia, hypotension/shock, arrhythmias, ischemia, chest pain

13. Clinical Manifestations of Anaphylaxis Urticaria Angioedema Upper airway edema Dyspnea and wheezing Flush Dizziness, syncope, and hypotension Gastrointestinal symptoms Rhinitis Headache Substernal pain Itch without rash –Pruritus Seizure

14. Clinical Course of Anaphylaxis Uniphasic Biphasic –Recurrence up to 8 hours later Different in Peds –Descriptions and perceptions are different Protracted –Hours to days

15. Anaphylaxis Fatalities Estimated 500–1000 deaths annually 1% risk Risk factors: –Failure to administer epinephrine immediately –Peanut, Soy & tree nut allergy (foods in general) –Beta blocker, ACEI therapy –Asthma –Cardiac disease –Rapid IV allergen –Atopic dermatitis ( eczema)

16. Food-induced Anaphylaxis: Common Triggers Children and adults (usually not outgrown): –Peanuts (Beware Atrovent) –Tree nuts –Shellfish –Fish Additional triggers in children (commonly outgrown): –Milk –Egg –Soy –Wheat

17. Food-induced Anaphylaxis: Common Symptoms Oropharynx: Oral pruritus, swelling of lips and tongue, throat tightening GI: Crampy abdominal pain, nausea, vomiting, diarrhea Cutaneous: Urticaria, angioedema Respiratory: Shortness of breath, stridor, cough, wheezing

18. Latex-induced Anaphylaxis: Incidence 1%–6% of US population (up to 16 million) affected –H igh as 67% in patients with spina bifida –6.5% in patients who have undergone multiple surgeries 3%–18% incidence among health care workers Repeated exposure leads to a higher risk Incidence has increased since mid 1980s –Latex gloves, especially powdered gloves –ETT, IV Tubing and Caths. –Nasal Canulas.

19. Latex-induced Anaphylaxis Hypoallergenic The "hypoallergenic" label generally means that gloves are low in chemical contact sensitizers, but "hypoallergenic" does not refer to latex allergens.

20. Latex-induced Anaphylaxis: Triggers Proteins in natural rubber latex Component of ~40,000 commonly used items –Rubber bands –Elastic (undergarments) –Hospital and dental equipment Latex-dipped products are biggest culprits –Balloons, gloves, bandages, hot water bottles

21. Reactions to Latex Irritant contact dermatitis Dry, itchy, irritated hands Allergic contact dermatitis Delayed hypersensitivity Latex allergy Immediate hypersensitivity Sx: hives, itching, sneezing, rhinitis, dyspnea, cough, wheezing Greatest risk with mucosal contact

22. Latex-induced Anaphylaxis: Prevention Use latex-free products Alert employer/health care providers, schools about need for latex-free products and equipment Wear MedicAlert  bracelet Awareness of cross-sensitivity with foods: AVOIDANCE –Banana –Avocado –Chestnuts –Kiwi –Stone fruit –Others

23. Exercise-Induced Anaphylaxis First reported in 1979 Mechanism of action is unclear Predisposing factors: –ASA –Food, including shell fish, cheese, dense fruits, snails. Triggered by almost any physical exertion Most common in very athletic children

24. Exercise-Induced Anaphylaxis Four Phases –Prodromal phase is characterized by fatigue, warmth, pruritus, and cutaneous erythema –The early phase: urticarial eruption that progresses from giant hives may include angioedema of the face, palms, and soles. –Fully established phase: hypotension, syncope, loss of consciousness, choking, stridor, nausea, and vomiting ( 30 minutes to 4 hours.) –Late or postexertional phase, Prolonged urticaria and headache persisting for 24-74 hours.

25. Other Causes of Anaphylactic and Anaphylactoid Reactions Drugs –Antibiotics –Chemotherapeutic agents –Aspirin, NSAIDs –Streptokinaise –Biologicals (vaccines, monoclonal antibodies) Radiocontrast media (iodine) Idiopathic

26. Diagnosing Anaphylaxis Based on clinical presentation, exposure Hx Cutaneous, respiratory Sx most common Some cases may be difficult to diagnose –Vasovagal syncope –Systemic mastocytosis

27. Diagnosing Anaphylaxis Careful history to identify possible causes Can be confirmed by serum tryptase –Specific for mast cell degranulation –Remains elevated for up to 6 hours Other labs to rule out other diagnoses Refer to allergist for specific testing

28. Use of Epi Pen Immediate treatment with epinephrine imperative –No contraindications in anaphylaxis –Failure or delay associated with fatalities –IM may produce more rapid, higher peak levels vs SC –Must be available at all times

29. EpiPen  /EpiPen  Jr: Directions for Use

30. EpiPen  /EpiPen  Jr: Directions for Use

31. EpiPen  /EpiPen  Jr: Directions for Use

32. Treatment of Anaphylaxis Simple BLS (O2, position, etc) Anti Histamines –Benadryl (IV 25-50 mg, PO 50 mg adult, 25 mg ped) Corticosteroids –Decadron, Solu-medrol, etc Treat Hypotension –IV fluids –Dopamine 5-20 mcg/min –Epi Drip 2-10 mcg/min

33. EpiPen ® 2-Pak * EpiPen ® 2-Pak  was launched in April 2001