What medication should be administered to a patient experiencing frothing during dialysis, potentially due to anaphylaxis?

Immediate Management of Frothing During Dialysis

Administer epinephrine (adrenaline) immediately—50 mcg IV (0.5 mL of 1:10,000 solution) for adults, repeated every 5-15 minutes as needed—as this is anaphylaxis until proven otherwise. 1

Recognition and Initial Response

Frothing during dialysis represents a life-threatening anaphylactic reaction requiring immediate intervention. The clinical presentation suggests severe respiratory involvement with potential airway compromise and cardiovascular collapse. 1, 2

Stop the dialysis immediately and remove all potential causative agents, including the dialyzer membrane, tubing, and any IV colloids. 1 Maintain vascular access for medication administration. 1

Primary Pharmacologic Management: Epinephrine

Epinephrine is the only first-line medication and must be given without delay. 1, 3 In the dialysis setting with established IV access:

• Adults: Administer 50 mcg IV (0.5 mL of 1:10,000 solution) initially, repeating every 5-15 minutes until clinical response. 1
• Children: Administer 1 mcg/kg IV (0.1 mL/kg of 1:10,000 solution), maximum 1 mg per dose. 1
• If multiple doses are required, initiate continuous IV epinephrine infusion at 0.1-1.0 mcg/kg/min, titrated to clinical effect. 1

The intramuscular route (0.3-0.5 mg of 1:1,000 solution in the lateral thigh) is an alternative if IV access is compromised, though less ideal in this setting. 1

Concurrent Supportive Measures

While administering epinephrine, simultaneously implement these interventions:

• Airway management: Administer 100% oxygen immediately; intubate if airway compromise progresses despite epinephrine. 1
• Positioning: Place patient in Trendelenburg position if hypotensive; sitting upright if respiratory distress predominates. 1
• Volume resuscitation: Infuse normal saline or lactated Ringer's at high rates (5-10 mL/kg in first 5 minutes, then 20 mL/kg boluses as needed). 1
• Call for help: Activate emergency response team immediately. 1

Secondary Medications (After Epinephrine)

Only after epinephrine administration, consider adjunctive therapy:

• H1 antihistamine: Diphenhydramine 50 mg IV slowly. 1
• H2 antihistamine: Ranitidine 50 mg IV slowly. 1
• Corticosteroids: Hydrocortisone 200 mg IV (adults) or methylprednisolone 1-2 mg/kg IV to prevent biphasic reactions. 1

Critical caveat: These adjunctive medications have much slower onset than epinephrine and should never be used alone or delay epinephrine administration. 1

Management of Refractory Symptoms

For persistent bronchospasm despite adequate epinephrine:

• Nebulized albuterol 2.5-5 mg in 3 mL saline, repeated as necessary. 1
• Consider IV salbutamol infusion, aminophylline, or magnesium sulfate. 1

For refractory hypotension despite epinephrine and fluids:

• Dopamine infusion 2-20 mcg/kg/min, titrated to maintain systolic BP >90 mmHg. 1
• Alternative vasopressors (vasopressin 0.01-0.04 U/min or norepinephrine) may be needed. 1

For patients on beta-blockers (which blunt epinephrine response):

• Glucagon 1-5 mg IV over 5 minutes, followed by infusion of 5-15 mcg/min. 1

Post-Resuscitation Management

• Obtain mast cell tryptase levels: Draw initial sample during resuscitation, second at 1-2 hours, third at 24 hours to confirm anaphylaxis. 1, 4
• Observe for biphasic reactions: Monitor vital signs continuously for minimum 4-6 hours; consider 24-hour observation for severe reactions. 1, 5
• Transfer to ICU for ongoing hemodynamic monitoring and potential prolonged resuscitation. 1

Critical Pitfalls to Avoid

Do not delay epinephrine while administering antihistamines or corticosteroids—this is the most common fatal error. 1, 3 Epinephrine works within minutes; other medications take 30-60 minutes and do not reverse life-threatening symptoms. 1, 6

Do not use subcutaneous epinephrine in anaphylaxis with cardiovascular collapse—absorption is unreliable in shock states. 7, 3

Do not restart dialysis with the same equipment—the patient has demonstrated anaphylaxis to an unidentified dialysis component and requires allergist evaluation before future dialysis. 2

Identification of Causative Agent

Dialyzer reactions can result from:

• Dialysis membrane material (polysulfone, cellulose-based membranes). 2
• Ethylene oxide sterilization residues. 2
• Heparin or other anticoagulants. 2
• Chlorhexidine or other antiseptics. 1

Mandatory allergist referral for comprehensive evaluation including skin testing to dialysis components before resuming treatments. 5, 2