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Safety of Epinephrine Administration in Anaphylaxis Treatment

Anaphylaxis is the rapid onset of an allergic reaction that is very serious and can cause death. Generally, the management to overcome this condition has the same procedure. However, there are different factors in each case, such as age, gender, to accompanying diseases. The Guideline of the American Academy of Allergy, Asthma & Immunology (AAAAI) clearly states that epinephrine administration by IM in treating anaphylaxis is the most recommended therapy. Administration of epinephrine by IM will result in peak concentrations in plasma, which are quite fast when compared to administration by subcutaneous (SC), both in children and adults.

Safety of Epinephrine Administration in Anaphylaxis Treatment

On the other hand, antihistamines and corticosteroids are not recommended for first-line treatment of anaphylaxis. In the case of allergic reactions, antihistamines, such as diphenhydramine, require a more extended mechanism of action and require a slower time to reach their peak when compared to epinephrine. One study showed that antihistamines to reduce 50% of allergy symptoms after administration, took 52 minutes for diphenhydramine IM, 80 minutes for diphenhydramine orally, up to 101 minutes for fexofenadine. Meanwhile, to overcome a fatal anaphylactic reaction, it takes less than 5 minutes since someone is exposed to allergens. Therefore, the use of antihistamines is not recommended to treat anaphylaxis.

Likewise, corticosteroids require a slower working time, so it is not recommended for treatment in anaphylactic conditions. Corticosteroids can prevent the recurrence of allergic events, so they are given as additional or advanced therapy, which can be given after epinephrine administration. Giving antihistamines and corticosteroids is to control the clinical manifestations of allergic skin and cardiovascular, such as itching, urticaria, angioedema, to symptoms of the nose and eyes. Also, to prevent the recurrence of allergic events.

Dosage and Methods for Administration of Epinephrine in the Anaphylaxis Treatment

Appropriate management of anaphylaxis is giving epinephrine injection IM (usually in the vastus lateral area) immediately. The dose is 0.01 mg / Kg weight (from a 1: 1,000 or 1 mg / mL epinephrine solution), the maximum dose of 0.5 mg at adults and 0.3 mg in children. The dose of epinephrine injection can be repeated every 5-15 minutes, as needed. Most patients require 1 to 2 times the dose of IM epinephrine injection. However, sometimes giving more than two times the dose can occur.

Intravenous administration of epinephrine can be considered especially for cases of severe hypotension, patients with cardiac and respiratory arrest, or patients who do not respond after repeated IM injections. Epinephrine infusion can be prepared by adding 1 mg (1 mL) 1: 1,000 ratio epinephrine to 250 mL of 5% dextrose solution to reach a concentration of 4 µg / mL. This 1: 250,000 liquid is then given at a rate of 1 mcg/minute (15 drops/minute with microdroplets), which can be increased according to the hemodynamic response, up to a maximum of 10 mcg/minute in adolescent and adult patients. It is safer to administer this epinephrine infusion using an infusion pump.

Causing Factors the Error with Epinephrine Dosage in the Anaphylaxis Management 

Factors that can lead to dose errors in the administration of epinephrine, especially in the anaphylaxis treatment, include:

- Lack of doctor's knowledge about the proper dosage and method of epinephrine administration in handling anaphylactic cases

- The absence of clear labeling distinguishes epinephrine ampules between 1: 1,000 and 1: 10,000, which results in inaccurate dosing.

- Store both epinephrine solutions in the same place, especially if the drugs are stored in alphabetical order.

- Difficulty in calculating doses involving decimal numbers and epinephrine dose ratios.

- Lack of communication between doctors and nurses is regarding the dose of epinephrine or the ratio of epinephrine dose used.

One study found that 94% of pediatric emergency physicians who were able to identify anaphylactic cases and provide epinephrine as their preferred management, only 67% of them gave epinephrine by IM probably since there are still many doctors who are not used to using epinephrine as the main therapy to their doubts about the safety of using epinephrine in anaphylactic cases.

Safety of Epinephrine Administration in Anaphylactic Treatment

Overdoses and cardiovascular side effects can occur with epinephrine administration. However, these overdoses and side effects usually appear more often in IV administration than IM.

A cohort study of 573 patients, of which 301 patients received at least one dose of epinephrine showed that of the 362 epinephrine doses given, 67.7% were IM auto injections, 19.6% were IM injections, 8.3% SC injections, 3.3% IV bolus injections, and 1.1% IV infusions. Moreover, it was found that the administration of epinephrine overdose occurred in 4 patients, and all were given by IV bolus injection whereas cardiovascular side effects appeared in 3 patients from 30 doses of IV bolus injection (10%), compared with four patients out of 316 doses given IM (1.3%). Therefore, IV administration of epinephrine in anaphylactic cases must be seriously considered, given the cardiovascular side effects it can cause.

The intramuscular injection of epinephrine administration is safe for anaphylaxis, but it requires the skills of doctors and medical workers to minimize dosage errors and methods of drug administration. Essential points to improve the safety of using epinephrine in anaphylaxis management are:

Epinephrine is the first-line treatment of anaphylaxis, while antihistamines and corticosteroids are adjunctive therapies.

Epinephrine for the management of anaphylaxis must be given intramuscularly, and not intravenously. Administration of intravenous epinephrine only when indicated.

The epinephrine given in the treatment of anaphylaxis is  1: 1,000 concentration epinephrine solution, not  1: 10,000 epinephrine solution.

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