| 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
- 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.
- For hypotension that remains refractory during epinephrine administration, add another vasopressor:
- Vasopressin (1 to 2 units bolus and/or infusion)
- or
- Norepinephrine infusion (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 (eg, echocardiography [transthoracic or transesophageal]) to diagnose cause(s).
- If patient has received high-dose beta blockers, consider vasopressin infusion or glucagon (1 to 5 mg slow IV bolus over 5 minutes) for refractory shock.
|
| 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 or recovery room for 12 to 24 hours.
- Continue glucocorticoids for 24 hours.
- Refer to allergist.
|
