| Signs (and symptoms, if patient can communicate) |
- Hypotension/shock.
- Tachycardia/arrhythmias.
- Dyspnea/wheezing/high peak inspiratory pressure/bronchospasm.
- Hypoxemia or decreased O2 saturation noted on pulse oximetry.
- Decreased breath sounds.
- Angioedema (face, lips, laryngeal stridor).
- Hives/itching.
- Flushing.
|
| Immediate actions |
- Call for help. Inform team and surgeon. Get code cart.
- Check for possible causes: Stop antibiotics, muscle relaxants, IV contrast, blood products, and latex exposure.
- Administer 100% FiO2.
- Secure or establish airway.
- For hypotension/shock, give epinephrine bolus (may repeat or escalate dose in 1 to 2 minutes and titrate to effect).
- Dosing 10 to 100 mcg per IV bolus.
- If no detectable blood pressure, then initiate ACLS protocol and administer fluid bolus (approximately 25 to 50 mL/kg).
- For ongoing hypotension, start IV infusion of epinephrine.
- Dosing 2 to 10 mcg/minute, titrated to effect.
|
| Other therapies for anaphylaxis (if signs/symptoms persist) |
- Albuterol: 4 to 8 puffs initially for bronchospasm; alternatively, 2.5 mg albuterol in 2.5 mL of saline nebulized for administration via the endotracheal tube.
- Methylprednisolone: 125 mg IV or hydrocortisone: 100 mg IV.
- H1 antihistamines: Diphenhydramine: 50 mg IV.
- H2 antihistamines: Famotidine: 20 mg IV (or cimetidine).
- Vasopressin for refractory hypotension (1 to 2 units bolus or infusion).
- Norepinephrine infusion for refractory hypotension as an alternative (2 to 10 mcg/minute titrated to effect).
- Continue fluid administrations for refractory hypotension up to 50 mL/kg; after the first 2 liters or fluid resuscitation for refractory shock, further hemodynamic monitoring should be considered.
- Consider vasopressin or glucagon (1 to 5 mg slow IV bolus over 5 minutes) for refractory shock if patient has received high-dose beta-blockers.
- Echocardiography (transthoracic or transesophageal) to diagnose cause of refractory hypotension.
|
| Consider and exclude other causes of signs/symptoms |
- Pneumothorax/tension pneumothorax.
- Pericardial tamponade.
- Myocardial infarction.
- Aspiration.
- Pulmonary edema.
- Air or pulmonary embolus.
|
| If patient develops cardiovascular collapse |
- Go to ACLS protocols for:
- Asystole/PEA.
- VF/VT.
- No detectable blood pressure.
|
| Send serum tryptase |
- Obtain at least 1 mL of blood in a red top tube for serum tryptase assay, ideally within 1 hour, but may remain elevated up to 3 hours from onset of event. Repeat serum tryptase after 24 hours to establish baseline concentration.
|
| After resuscitation |
- Observe patient in the intensive care unit recovery room for 12 to 24 hours.
- Continue glucocorticoids for 24 hours.
- Refer to allergist.
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