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. 2004 Mar;21(2):149–154. doi: 10.1136/emj.2003.009449

Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation

S Brown 1, K Blackman 1, V Stenlake 1, R Heddle 1
PMCID: PMC1726302  PMID: 14988337

Abstract

Objectives: To assess a protocol for treatment of sting anaphylaxis.

Design: Prospective assessment of treatment with oxygen, intravenous infusion of adrenaline (epinephrine), and volume resuscitation with normal saline.

Setting: Sub-study of a venom immunotherapy trial.

Participants: 21 otherwise healthy adults with systemic allergic reactions to diagnostic sting challenge.

Main outcome measures: Response to treatment, total adrenaline dose and infusion duration, recurrence of symptoms after stopping the infusion, and additional volume resuscitation.

Results: 19 participants required intervention according to the protocol. All received adrenaline, and five received volume resuscitation. In nine cases, physical signs of anaphylaxis recurred after initial attempts at stopping adrenaline but resolved after recommencing the infusion. The median total dose and infusion duration were 590 µg and 115 minutes respectively, but were significantly higher for eight patients who had hypotensive reactions (762 µg and 169 minutes respectively). Hypotension was always accompanied by a relative bradycardia, which was severe and treated with atropine in two patients. Widespread T wave inversion occurred, before starting treatment with adrenaline, in one person with an otherwise mild reaction. All patients fully recovered and were fit for same day discharge, apart from the person with ECG changes who was observed overnight and discharged the following day.

Conclusions: Carefully titrated intravenous adrenaline combined with volume resuscitation is an effective strategy for treating sting anaphylaxis, however severe bradycardia may benefit from additional treatment with atropine. Cardiac effects of anaphylaxis, perhaps including neurocardiogenic mechanisms, may be an important factor in some lethal reactions.

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Selected References

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  1. Abboud F. M. Neurocardiogenic syncope. N Engl J Med. 1993 Apr 15;328(15):1117–1120. doi: 10.1056/NEJM199304153281510. [DOI] [PubMed] [Google Scholar]
  2. Abboud F. M. Ventricular syncope: is the heart a sensory organ? N Engl J Med. 1989 Feb 9;320(6):390–392. doi: 10.1056/NEJM198902093200609. [DOI] [PubMed] [Google Scholar]
  3. Bautista Edgar, Simons F. Estelle R., Simons Keith J., Becker Allan B., Duke Krika, Tillett Michelle, Kepron Wayne, Mink Steven N. Epinephrine fails to hasten hemodynamic recovery in fully developed canine anaphylactic shock. Int Arch Allergy Immunol. 2002 Jun;128(2):151–164. doi: 10.1159/000059406. [DOI] [PubMed] [Google Scholar]
  4. Blaauw P. J., Smithuis O. L., Elbers A. R. The value of an in-hospital insect sting challenge as a criterion for application or omission of venom immunotherapy. J Allergy Clin Immunol. 1996 Jul;98(1):39–47. doi: 10.1016/s0091-6749(96)70224-5. [DOI] [PubMed] [Google Scholar]
  5. Brown A. F. Anaphylaxis: quintessence, quarrels, and quandaries. Emerg Med J. 2001 Sep;18(5):328–328. doi: 10.1136/emj.18.5.328. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Brown S. G., Wu Q. X., Kelsall G. R., Heddle R. J., Baldo B. A. Fatal anaphylaxis following jack jumper ant sting in southern Tasmania. Med J Aust. 2001 Dec 3;175(11-12):644–647. doi: 10.5694/j.1326-5377.2001.tb143761.x. [DOI] [PubMed] [Google Scholar]
  7. Brown Simon G. A., Wiese Michael D., Blackman Konrad E., Heddle Robert J. Ant venom immunotherapy: a double-blind, placebo-controlled, crossover trial. Lancet. 2003 Mar 22;361(9362):1001–1006. doi: 10.1016/S0140-6736(03)12827-9. [DOI] [PubMed] [Google Scholar]
  8. Fisher M. M. Clinical observations on the pathophysiology and treatment of anaphylactic cardiovascular collapse. Anaesth Intensive Care. 1986 Feb;14(1):17–21. doi: 10.1177/0310057X8601400105. [DOI] [PubMed] [Google Scholar]
  9. Fisher M. Treating anaphylaxis with sympathomimetic drugs. BMJ. 1992 Nov 7;305(6862):1107–1108. doi: 10.1136/bmj.305.6862.1107. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Fisher M. Treatment of acute anaphylaxis. Letters contained errors of logic. BMJ. 1996 Mar 9;312(7031):637–638. doi: 10.1136/bmj.312.7031.637c. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Kemp Stephen F., Lockey Richard F. Anaphylaxis: a review of causes and mechanisms. J Allergy Clin Immunol. 2002 Sep;110(3):341–348. doi: 10.1067/mai.2002.126811. [DOI] [PubMed] [Google Scholar]
  12. Mitsuhata H., Shimizu R., Yokoyama M. M. Role of nitric oxide in anaphylactic shock. J Clin Immunol. 1995 Nov;15(6):277–283. doi: 10.1007/BF01541317. [DOI] [PubMed] [Google Scholar]
  13. Otero E., Onufer J. R., Reiss C. K., Korenblat P. E. Anaphylaxis-induced myocardial depression treated with amrinone. Lancet. 1991 Mar 16;337(8742):682–682. doi: 10.1016/0140-6736(91)92508-y. [DOI] [PubMed] [Google Scholar]
  14. Patella V., Marinò I., Lampärter B., Arbustini E., Adt M., Marone G. Human heart mast cells. Isolation, purification, ultrastructure, and immunologic characterization. J Immunol. 1995 Mar 15;154(6):2855–2865. [PubMed] [Google Scholar]
  15. Pumphrey R. S. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000 Aug;30(8):1144–1150. doi: 10.1046/j.1365-2222.2000.00864.x. [DOI] [PubMed] [Google Scholar]
  16. Raper R. F., Fisher M. M. Profound reversible myocardial depression after anaphylaxis. Lancet. 1988 Feb 20;1(8582):386–388. doi: 10.1016/s0140-6736(88)91184-1. [DOI] [PubMed] [Google Scholar]
  17. Sampson H. A., Mendelson L., Rosen J. P. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med. 1992 Aug 6;327(6):380–384. doi: 10.1056/NEJM199208063270603. [DOI] [PubMed] [Google Scholar]
  18. Schadt J. C., Ludbrook J. Hemodynamic and neurohumoral responses to acute hypovolemia in conscious mammals. Am J Physiol. 1991 Feb;260(2 Pt 2):H305–H318. doi: 10.1152/ajpheart.1991.260.2.H305. [DOI] [PubMed] [Google Scholar]
  19. Smith P. L., Kagey-Sobotka A., Bleecker E. R., Traystman R., Kaplan A. P., Gralnick H., Valentine M. D., Permutt S., Lichtenstein L. M. Physiologic manifestations of human anaphylaxis. J Clin Invest. 1980 Nov;66(5):1072–1080. doi: 10.1172/JCI109936. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Stark B. J., Sullivan T. J. Biphasic and protracted anaphylaxis. J Allergy Clin Immunol. 1986 Jul;78(1 Pt 1):76–83. doi: 10.1016/0091-6749(86)90117-x. [DOI] [PubMed] [Google Scholar]
  21. Zaloga G. P., DeLacey W., Holmboe E., Chernow B. Glucagon reversal of hypotension in a case of anaphylactoid shock. Ann Intern Med. 1986 Jul;105(1):65–66. doi: 10.7326/0003-4819-105-1-65. [DOI] [PubMed] [Google Scholar]
  22. van der Linden P. W., Hack C. E., Poortman J., Vivié-Kipp Y. C., Struyvenberg A., van der Zwan J. K. Insect-sting challenge in 138 patients: relation between clinical severity of anaphylaxis and mast cell activation. J Allergy Clin Immunol. 1992 Jul;90(1):110–118. doi: 10.1016/s0091-6749(06)80017-5. [DOI] [PubMed] [Google Scholar]
  23. van der Linden P. W., Hack C. E., Struyvenberg A., van der Zwan J. K. Insect-sting challenge in 324 subjects with a previous anaphylactic reaction: current criteria for insect-venom hypersensitivity do not predict the occurrence and the severity of anaphylaxis. J Allergy Clin Immunol. 1994 Aug;94(2 Pt 1):151–159. doi: 10.1016/0091-6749(94)90034-5. [DOI] [PubMed] [Google Scholar]
  24. van der Linden P. W., Struyvenberg A., Kraaijenhagen R. J., Hack C. E., van der Zwan J. K. Anaphylactic shock after insect-sting challenge in 138 persons with a previous insect-sting reaction. Ann Intern Med. 1993 Feb 1;118(3):161–168. doi: 10.7326/0003-4819-118-3-199302010-00001. [DOI] [PubMed] [Google Scholar]

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