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J ALLERGY CLIN IMMUNOL VOLUME 115, NUMBER 3 Lieberman et al S485 The diagnosis and management of anaphylaxis: An updated practice parameter Preface S485 Algorithm for initial evaluation and management of a patient with a history of anaphylaxis (Fig 1) S486 Algorithm for the treatment of acute anaphylaxis (Fig 2) S489 Summary statements S494 Evaluation and management of the patient with a history of episodes of anaphylaxis S497 Management of anaphylaxis S500 Anaphylaxis to foods S506 Latex-induced anaphylaxis S508 Anaphylaxis during general anesthesia, the intraoperative period, and the postoperative period S509 Seminal fluid–induced anaphylaxis S511 Exercise-induced anaphylaxis S513 Idiopathic anaphylaxis S514 Anaphylaxis and allergen immunotherapy vaccines S515 Anaphylaxis to drugs S516 Prevention of anaphylaxis S518 Rufus E. Lee, MD Private Practice Dothan, Alabama Jay M. Portnoy, MD Section of Allergy, Asthma & Immunology The Children’s Mercy Hospital Professor of Pediatrics University of Missouri-Kansas City School of Medicine Kansas City, Missouri Diane E. Schuller, MD Department of Pediatrics Pennsylvania State University Milton S. Hershey Medical College Hershey, Pennsylvania Sheldon L. Spector, MD Department of Medicine UCLA School of Medicine Los Angeles, California Stephen A. Tilles, MD Department of Medicine University of Washington School of Medicine Redmond, Washington REVIEWERS Mary C. Tobin, MD, Oak Park, Illinois Jeffrey A. Wald, MD, Overland Park, Kansas Dana V. Wallace, MD, Fort Lauderdale, Florida Stephen Wasserman, MD, La Jolla, California CLASSIFICATION OF RECOMMENDATIONS AND EVIDENCE Category of evidence Ia Evidence from meta-analysis of randomized controlled trials Ib Evidence from at least one randomized controlled trial IIa Evidence from at least on controlled study without randomization IIb Evidence from at least one other type of quasiexperimental study III Evidence from nonexperimental descriptive studies, such as comparative studies IV Evidence from expert committee reports or opinions or clinical experience of respected authorities or both Strength of recommendation A Directly based on category I evidence B Directly based on category II evidence or extrapolated recommendation from category I evidence C Directly based on category III evidence or extrapolated recommendation from category I or II evidence D Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence NR Not rated PREFACE Anaphylaxis is defined for the purposes of this document as a condition caused by an IgE-mediated reaction. Anaphylactoid reactions are defined as those reactions that produce the same clinical picture as anaphylaxis but are not IgE mediated. Where both IgE-mediated and non–IgEmediated mechanisms are a possible cause, the term ‘‘anaphylactic’’ has been used to describe the reaction. Anaphylactic reactions are often life-threatening and almost always unanticipated. Even when there are mild symptoms initially, the potential for progression to a severe and even irreversible outcome must be recognized. Any delay in the recognition of the initial signs and symptoms of anaphylaxis can result in a fatal outcome either because of airway obstruction or vascular collapse. Most patients who have experienced anaphylaxis should be evaluated by a specialist in allergy-immunology. Such a consultation is appropriate because individuals trained in allergy-immunology possess particular training and skills to evaluate and appropriately treat individuals at risk of anaphylaxis. The objective of this parameter, ‘‘The diagnosis and management of anaphylaxis: an updated practice parameter,’’ is to improve the care of patients by providing the practicing physician with an evidence-based approach to the diagnosis and management of anaphylactic reactions.
S486 Lieberman et al J ALLERGY CLIN IMMUNOL MARCH 2005 ‘‘The diagnosis and management of anaphylaxis: an updated practice parameter’’ was developed by the Joint Task Force on Practice Parameters, which has published 11 practice parameters for the field of allergy-immunology (see list of publications). The 3 national allergy and immunology societies—the American College of Allergy, Asthma and Immunology (ACAAI); the American Academy of Allergy, Asthma and Immunology (AAAAI); and the Joint Council of Allergy, Asthma and Immunology (JCAAI)—have given the Joint Task Force the responsibility for both creating new parameters and updating existing parameters. This parameter builds on ‘‘The diagnosis and management of anaphylaxis,’’ which was published in 1998 by the Joint Task Force on Practice Parameters. It was written and reviewed by specialists in the field of allergy and immunology and was exclusively funded by the 3 allergy and immunology organizations noted above. A workgroup chaired by Phillip Lieberman, MD, prepared the initial draft. The Joint Task Force then reworked the initial draft into a working draft of the document. A comprehensive search of the medical literature was conducted with various search engines, including PubMed, using appropriate search terms. Published clinical studies were rated by category of evidence and used to establish the strength of the clinical recommendations (see ‘‘Classification of rating and evidence’’ above). The working draft of this updated parameter was reviewed by a large number of experts on anaphylaxis selected by the sponsoring organizations. This document represents an evidence-based and broadly accepted consensus viewpoint on the diagnosis and management of anaphylaxis. ‘‘The diagnosis and management of anaphylaxis: an updated practice parameter’’ contains annotated algorithms that present the major decision points for the initial evaluation and management of a patient with a history of a previous episode of anaphylaxis and for the acute management of anaphylaxis. These are followed by a list of summary statements that represent the key points to consider in the evaluation and management of anaphylaxis. These summary statements can also be found before each section in this document followed by the text that supports the summary statements, which are, in turn, followed by graded references that support the statements in the text. In addition to sections on the diagnosis and management of anaphylaxis, this updated parameter contains sections on anaphylaxis to foods, latex, seminal fluid, allergen immunotherapy, and medications, as well as exercise-induced anaphylaxis, idiopathic anaphylaxis, and anaphylaxis occurring during general anesthesia, both during the intraoperative and postoperative periods. Among the objectives of this updated parameter are the development of an improved understanding of anaphylaxis among health care professionals, medical students, interns, residents, and fellows, as well as managed care executives and administrators. The parameter is intended to provide guidelines and support for the practicing physician and to improve the quality of care for patients who experience anaphylaxis. The Joint Task Force on Practice Parameters recognizes that there are different, although appropriate, approaches to the diagnosis and management of anaphylactic reactions that often require flexible recommendations. Therefore the diagnosis and management of anaphylactic reactions must be individualized on the basis of unique features in particular patients. Throughout this document, we will rely on anaphylaxis to imply anaphylactic (IgE-mediated) and anaphylactoid (non–IgE-mediated) reactions. The Joint Task Force on Practice Parameters wishes to thank the ACAAI, AAAAI, and JCAAI, who have supported the preparation of this updated parameter, and the large number of individuals who have so kindly dedicated their time and effort to the review of this document. ALGORITHM FOR INITIAL EVALUATION AND MANAGEMENT OF A PATIENT WITH A HISTORY OF ANAPHYLAXIS (Fig 1) Annotation 1: Is the history consistent with a previous episode of anaphylaxis? All individuals who have had a known or suspected anaphylactic episode require a careful and complete review of their clinical history. This history might elicit manifestations, such as urticaria, angioedema, flushing, pruritus, upper airway obstruction, gastrointestinal symptoms, syncope, hypotension, lower airway obstruction, and/or dizziness. Of primary importance is the nature of the symptoms characterizing the event. Essential questions to be asked are as follows: 1. Were there cutaneous manifestations, specifically pruritus, flush, urticaria, and angioedema? 2. Was there any sign of airway obstruction involving either the upper airway or the lower airway? 3. Were there gastrointestinal symptoms (ie, nausea, vomiting, or diarrhea)? 4. Were syncope or presyncopal symptoms present? At this point, it should be noted that the absence of cutaneous symptoms puts the diagnosis in question because the majority of anaphylaxis includes cutaneous symptoms, but their absence would not necessarily rule out an anaphylactic or anaphylactoid event. The history should concentrate on agents encountered before the reaction. Whenever appropriate, the information should be obtained from not only the patient but also family members or other witnesses. The complete sequence of events must be reviewed, with special attention paid to the cardiorespiratory symptoms. Medical records, including medication records, can often be useful in evaluating the history, physical findings, and treatment of the clinical event. In addition, the results of any previous laboratory studies (eg, serum tryptase levels) might be helpful in making the diagnosis of anaphylaxis or distinguishing it from other entities.
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References Acknowledgment: Linda Co
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