What is the inpatient management of anaphylaxis?

From the Guidelines

Inpatient management of anaphylaxis requires prompt recognition and immediate treatment with epinephrine as the first-line therapy. For patients experiencing anaphylaxis, administer epinephrine 0.01 mg/kg of a 1:1000 solution to a maximum of 0.5 mg in adults and 0.3 mg in children intramuscularly in the anterolateral thigh, which can be repeated every 5-15 minutes if symptoms persist, as recommended by the 2020 practice parameter update 1.

Key Considerations

• Position the patient supine with legs elevated unless respiratory distress is present.
• Secure the airway if needed and administer high-flow oxygen, as supplemental oxygen therapy is crucial in optimizing oxygen delivery and organ perfusion, and also helps with bronchodilation 1.
• Establish IV access for fluid resuscitation with normal saline (1-2 L rapidly for hypotension).
• Second-line medications include H1 antihistamines, H2 blockers, and corticosteroids to prevent biphasic reactions, although their role in anaphylaxis management is not clearly supported by evidence 1.
• For bronchospasm, add nebulized albuterol 2.5-5 mg.

Monitoring and Follow-up

• Continuous monitoring of vital signs, oxygen saturation, and cardiac rhythm is essential.
• After stabilization, identify and remove the trigger if possible.
• Patients should be observed for at least 24 hours due to the risk of biphasic reactions, which occur in up to 20% of cases.
• Prior to discharge, prescribe an epinephrine auto-injector, provide anaphylaxis education, and arrange follow-up with an allergist, as education on anaphylaxis and the use of epinephrine auto-injectors is crucial for patient management and safety 1.

Additional Recommendations

• Do not delay the administration of epinephrine for anaphylaxis, as doing so may be associated with higher morbidity and mortality 1.
• All patients with anaphylaxis should receive education on anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine auto-injectors 1.

From the Research

Inpatient Management of Anaphylaxis

The inpatient management of anaphylaxis involves several key steps, including:

• Immediate administration of epinephrine, which is the medication of choice for the treatment of anaphylaxis 2, 3, 4, 5, 6
• Administration of other medications, such as antihistamines and corticosteroids, as second-line treatments 3, 4, 5
• Aggressive fluid resuscitation to treat intravascular volume depletion 3, 4
• Patient observation and disposition, which should be individualized based on the severity of the reaction 3, 4

Medications Used in Anaphylaxis Treatment

The following medications are commonly used in the treatment of anaphylaxis:

• Epinephrine, which is the first-line treatment for anaphylaxis 2, 3, 4, 5, 6
• Antihistamines, which can be used as second-line treatments for mild anaphylactic reactions 3, 4, 5
• Corticosteroids, which can be used to prevent protracted or biphasic courses of anaphylaxis 3, 4, 5
• Glucagon, which can be used as a second-line treatment for anaphylaxis 5
• β2-adrenergic agonists, which can be used as second-line treatments for anaphylaxis 5

Administration of Epinephrine

Epinephrine should be administered immediately upon evidence of anaphylaxis, and can be given:

• Intramuscularly, into the anterolateral thigh, as the preferred method of administration 3, 4, 6
• Intravenously, in severe cases or under conditions of surgical interventions 4
• Using an epinephrine auto-injector, which can be prescribed for patients with known anaphylactic reactivity 2, 6