Anaphylaxis is a serious systemic allergic reaction, the incidence of which has increased in recent years, and which can occur rapidly and cause mortality[1]. It has been reported that the incidence of anaphylaxis is between 50–112 per 100 000 and the prevalence varies between 0.3–5.1% [2]. Anaphylaxis is a systemic reaction that develops due to mast cell and basophil-derived mediators. The causes of anaphylaxis vary according to the age group. Anaphylaxis usually occurs with immunological mechanisms after exposure to foods, drugs and bee venom. Non-immunological mechanisms may also play a role in the development of anaphylaxis by causing mast cell and basophil degranulation. Non-immunological factors include exercise, cold and various drugs (opiates, vancomycin, radiocontrast agent, cyclooxygenase (COX)-1 inhibitors). Drug-induced anaphylaxis is more common in the adult age group. Especially,anaphylaxis due to antibiotics is common. Beta Lactam group antibiotics are in the first place among the antibiotics that cause anaphylaxis. Non-steroidal anti-inflammatory drugs are the most common group of drugs that cause anaphylaxis after antibiotics. Due to the increase in the frequency of use of chemotherapy and biological agents in recent years, the incidence of anaphylaxis has increased with both drug groups. Anaphylaxis can develop with all drugs. Therefore, anaphylaxis is common in hospitalized patients. Rapid diagnosis and correct treatment in anaphylaxis prevent possible mortality and morbidity.
Diagnosis of anaphylaxis; Diagnostic criteria determined in international guidelines are made with the help of history and physical examination. Anaphylaxis diagnostic criteria are indicated in Table 1. Anaphylaxis usually occurs within the first 2 hours of encountering the trigger. Rarely, this period may take up to 4–6 hours. For this reason, in case of anaphylaxis, the drugs used and the foods consumed by the patient in the last 4–6 hours should be questioned [3]. Skin symptoms and signs are most common in anaphylaxis. Skin signs and symptoms are followed by respiratory system signs and symptoms. Upper respiratory symptoms and signs such as rhinitis may occur, as well as lower respiratory tract symptoms and signs such as laryngeal edema or bronchospasm may occur. Involvement of these two systems is followed by gastrointestinal and cardiovascular symptoms and signs [4]. Respiratory system or cardiovascular system symptoms and signs are the most important indicators for mortality and morbidity[5]. Anaphylaxis signs and symptoms are indicated in Table 2. Anaphylaxis diagnostic criteria are definite although it is difficult to diagnose because it shows clinical variability. In anaphylaxis, it may present as clinically mild, without severe symptoms such as desaturation, hypotension, and loss of consciousness. The clinic, which starts with mild symptoms and signs, may worsen over time. For this reason, the physician's recognition and intervention of mild anaphylaxis prevents the patient's clinical condition from worsening. The most common cause of fatal anaphylaxis is drugs, and a good anaphylaxis management can be life-saving in hospitalized patients [6].
Table 1
Diagnostic criteria for anaphylaxis
Anaphylaxis is highly likely when any ONE of the following three criteria is fulfilled: |
1. Acute onset of an illness [minutes to several hours] with involvement of the skin, mucosal tissue, or both [eg, generalized hives, pruritus or flushing, swollen lips-tongue-uvula] |
AND AT LEAST ONE OF THE FOLLOWING: |
A. Respiratory compromise [eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia] |
B. Reduced BP* or associated symptoms of end-organ dysfunction [eg, hypotonia, collapse, syncope, incontinence] |
2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to a LIKELY allergen for that patient [minutes to several hours]: |
A. Involvement of the skin mucosal tissue [eg, generalized hives, itch-flush, swollen lips-tongue-uvula] |
B. Respiratory compromise [eg, dyspnea, wheeze-bronchospasm, stridor, hypoxemia] |
C. Reduced BP* or associated symptoms [eg, hypotonia, collapse, syncope, incontinence] |
D. Persistent gastrointestinal symptoms [eg, crampy abdominal pain, vomiting] |
3. Reduced BP* after exposure to a KNOWN allergen for that patient [minutes to several hours]: |
A. Infants and children - Low systolic BP [age-specific] * or greater than 30% decrease in systolic BP |
B. Adults - Systolic BP of less than 90 mmHg or greater than 30% decrease from that person's baseline |
Table 2
Anaphylaxis signs and symptoms
Systems | Symtpom and sings | Incidence [%] |
Skin | Feeling of warmth, flushing [erythema], itching, urticaria, angioedema, and "hair standing on end" [piloe erection], Itching or tingling of lips/ tongue/ palate, Edema of lips/tongue/ uvula, Periorbital itching/ erythema/ edema, tearing, and conjunctival erythema | 80–90 |
Respiratory | Nose - Itching, congestion, rhinorrhea, and sneezing Laryngeal - Itching and "tightness" in the throat, dysphonia, hoarseness, stridor Lower airways - Shortness of breath [dyspnea], chest tightness, cough, wheezing, and cyanosis | 70 |
Gastrointestinal | nausea, abdominal pain, vomiting, diarrhea, and dysphagia | 30–45 |
Cardiovascular | Feeling of faintness or dizziness; syncope, altered mental status, chest pain, palpitations, tachycardia, bradycardia or other dysrhythmia, hypotension, tunnel vision, difficulty hearing, urinary or fecal incontinence, and cardiac arrest | 10–45 |
Neurologic | Anxiety, apprehension, sense of impending doom, seizures, headache and confusion | 10–15 |
Other | Uterine cramps in women and girls, metallic taste | |
The most important laboratory test used in the diagnosis of anaphylaxis is the measurement of tryptase level. The tryptase level measured 24 hours after the patient's symptoms have resolved should be considered the baseline value. The increase in tryptase level of 20%+2 ng/ml compared to the basal level during the reaction supports the diagnosis of anaphylaxis[7]. Tryptase measurement is not done in every laboratory, unfortunately the results come out days or even weeks later in laboratories that can measure. This situation increases the importance of the clinic in the diagnosis of anaphylaxis.
Anaphylaxis is the most severe allergic reaction that can result in mortality and should be treated promptly after diagnosis. It is very important to cut off contact with the antigen that causes anaphylaxis after the patient's vital signs (blood pressure, heart rate, saturation measurement with pulse oximetry, etc.) are measured. To prevent the empty ventricle syndrome, the patient should be laid on his back and the legs should be raised. Thus, the venous return to the heart will increase and cardiac output will be preserved [8]. 8–10 L/min oxygen support should be provided to the patient with a mask. The first drug to be given in treatment is adrenaline. With adrenaline; Alpha-1 adrenergic receptors are activated and vasoconstriction increases, peripheral vascular resistance increases, mucosal edema decreases, inotropy and chronotropy increase with activation of beta-1 adrenergic receptors, and bronchodilation develops with activation of beta-2 adrenergic receptors [9]. Adrenaline is administered intramuscularly (IM) to the vastus lateralis muscle. The dose of adrenaline is 0.2–0.5 mg in the adult patient, the dose of adrenaline is 0.01 mg/kg in pediatric patients, and the maximum adrenaline dose is 0.30 mg. If symptoms and signs of anaphylaxis persist, im adrenaline is administered several times at intervals of 5–15 minutes. Intravenous (IV) adrenaline is administered to patients whose cardiogenic shock symptoms and signs persist despite im adrenaline therapy. In adult patients, iv adrenaline is started at a dose of 2–10 µg/min, and in pediatric patients at a dose of 0.1-1 µg/kg/min. it can be increased up to 10 µg/min in pediatric patients [10]. After the adrenaline treatment, the patient is given IV fluid replacement. It can be started with 10–20 ml/kg saline in ten minutes and fluid replacement up to 100 ml/kg can be done according to the patient's clinic. After adrenaline, the patient is given H1 antihistamine treatment. This treatment can be administered iv, im or orally. If necessary, antihistamine treatment can be repeated for 4–6 hours. 2 mg/kg of methylprednisolone (maximum 50 mg) can be administered IM, IV and orally. If necessary, the treatment can be repeated at intervals of 4–6 hours.
The European Society of Allergy and Clinical Immunology (EAACI)recommends monitoring for 6–8 hours in cases with respiratory complaints due to anaphylaxis, and monitoring for 12–24 hours in patients presenting with circulatory disorders [11]. Depending on the severity of anaphylaxis, patients should be kept under observation in the emergency room or intensive care unit.
In this study, our aim was to measure the awareness of anaphylaxis diagnosis and treatment of doctors working in different branches in the 3rd Stage Training and Research Hospital. Doctors from twenty different branches participated in the study.