Standardizing Anaphylaxis Treatment in Pediatric Care Settings

INTRODUCTION Anaphylaxis is a severe, rapid-onset hypersensitivity reaction with multisystem organ involvement.1 The reported lifetime prevalence of anaphylaxis is estimated to range from 1.6% to 5.1%.2,3 Despite established medical guidelines,1,2,4 misconceptions regarding the recognition and treatment of anaphylaxis continue to persist among healthcare providers, patients, and their caregivers, leading to delays in care and inadequate treatment.5 The most common cause of anaphylaxis in children and adults includes food, medication, and venom hypersensitivity.6 Approximately 20% of anaphylaxis-related fatalities are due to medications.5 Delayed or inappropriate treatment of anaphylaxis can be fatal. Intramuscular (IM) epinephrine is the first-line treatment for the management of anaphylaxis.4 IM epinephrine [administered at 0.01 mg/kg of a 1:1,000 concentration (maximum dose: 0.5 mg in adults and 0.3 mg in children)] be administered in the mid-anterolateral thigh is recommended for any episode of anaphylaxis.4 Antihistamines have a slow onset of action and are never used as the first-line treatment of anaphylaxis.2,7 There is limited evidence regarding the clinical benefit of glucocorticoids, which should also be avoided in the first-line treatment of anaphylaxis.2,8 Shaker et al2 describe the diagnosis of anaphylaxis based on clinical criteria (Table 1). Prompt assessment and early recognition of the signs and symptoms of anaphylaxis will ensure accurate diagnosis and timely administration of epinephrine, which can be life-saving by preventing progression to a fatal reaction. Anaphylaxis has been reported with the use of biologics and chemotherapeutic agents.9,10 Because third-party payers may deny an inpatient admission for these therapies, clinicians often administer them in the outpatient setting. Two unique cases of anaphylaxis led to the creation of the Anaphylaxis Work Group (AWG) at our center. Both cases took place in our outpatient infusion center. Case 1 involved a pediatric patient who experienced difficulty breathing and urticaria during a chemotherapy infusion with an agent known to cause anaphylaxis). The staff initially administered diphenhydramine, but symptoms persisted. At the time, the monitoring staff were unclear about whether to administer intravenous (IV) or IM epinephrine to treat anaphylaxis. In addition, when retrieving the epinephrine from the Omnicell (Omnicell, Santa Clara, Calif.), the appropriate needle gauge required for medication administration was unavailable. This issue led to further delays in emergent care. Ultimately, the staff administered IM Epinephrine, and the patient recovered without further complications. Case 2 involved a pediatric patient who experienced symptoms of cough and rash during a chemotherapy infusion. The staff identified this as a case of anaphylaxis, but they administered an inadequate dose of IV epinephrine. Persistent symptoms led to transfer to the intensive care unit, where the patient required a continuous epinephrine infusion but recovered without further sequelae. These events led to a formal evaluation to improve our center’s recognition and management of anaphylaxis. In this report, we describe our methodology and propose quality improvement tools for monitoring the impact of our interventions. From the *Department of Pediatrics, Texas Children’s Hospital, Section of Immunology, Allergy and Retrovirology, Baylor College of Medicine, Houston, Tex.; and †Department of Pediatrics, Texas Children’s Hospital, Section of Hematology/ Oncology, Baylor College of Medicine, Houston, Tex.