Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

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.