Multi-phasic life-threatening anaphylaxis refractory to epinephrine managed by extracorporeal membrane oxygenation (ECMO): A case report

Management of Refractory Anaphylaxis: An Overview of Current Guidelines

In this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second-line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta-blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor-acetyl hydrolase or hereditary alpha-tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis.

Disseminated Intravascular Coagulation in Anaphylaxis

Anaphylaxis is a life-threatening condition that involves severe cutaneous, respiratory, and cardiovascular symptoms. Disseminated intravascular coagulation (DIC) is an acquired, widespread activation of coagulation that can be caused by infectious conditions (e.g., sepsis) and noninfectious conditions. The onset of DIC following anaphylaxis is not commonly known, and information regarding the pathomechanism linking anaphylaxis to DIC is scarce. Further, demographic and clinical data in anaphylaxis-induced DIC are still missing to this day. Triggered by a case of anaphylaxis-induced DIC that seamlessly transitioned to lethal sepsis-induced DIC, we aimed to characterize the patient population affected by anaphylaxis-induced DIC by performing a review of existing literature and expand the discussion to underlying mechanisms. The overall mortality of the patient cohort (n = 30) identified by the literature review was 50%. All patients that died either suffered a bleeding event or a thrombotic event. The majority of patients (n = 25/30; 83%) had bleeding events; thrombotic events were only reported in nonsurvivors (n = 9/15 or 60% of nonsurvivors; vs. n = 0/15 in survivors; p < 0.001). Nonsurvivors of anaphylaxis-induced DIC were on average 25 years older than survivors (p = 0.068). In conclusion, DIC can complicate anaphylaxis and is expected to contribute to poor microvascular perfusion after anaphylaxis. Particularly, elderly patients with known cardiovascular disease and patients who develop thrombotic events are susceptible to lethal outcomes. As a rare and largely uncharacterized disease entity, further research is needed to investigate the link between DIC and anaphylaxis and to potentially identify better treatment strategies.

A Case of Anaphylactic Shock Suspected to Be Caused by Bovine Serum Albumin Tissue Adhesive (BioGlue) During Thoracoabdominal Aortic Replacement

Bovine serum albumin (BSA) tissue adhesive (BioGlue, Cryolife Inc., Kennesaw, GA, USA) is often used as a hemostatic adjunct in adult patients undergoing open surgical repair of large vessels, such as the aorta, femoral, and carotid arteries. We present a case of intraoperative anaphylaxis attributed to the use of BioGlue during thoracoabdominal aortic replacement. The patient suddenly developed hypotension, hypoxemia, and airway edema after the BioGlue application. BioGlue is composed of purified BSA and glutaraldehyde. Despite the BSA component being an allergen that can cause anaphylaxis in some patients, reported occurrences of anaphylaxis are extremely rare. We need to recognize BSA tissue adhesive as a potential allergen. In the event of an intraoperative shock, prompt recognition and investigation of the underlying cause are necessary.

Anaphylaxis mortality in the perioperative setting: Epidemiology, elicitors, risk factors and knowledge gaps

Perioperative anaphylaxis (PA) is a severe condition that can be fatal, but data on PA mortality are scarce. The aim of this article is to review the epidemiology, elicitors and risk factors for PA mortality and identify knowledge gaps and areas for improvement regarding the management of severe PA. PA affects about 100 cases per million procedures. Mortality is rare, estimated at 3 to 5 cases per million procedures, but the PA mortality rate is higher than for other anaphylaxis aetiologies, at 1.4% to 4.8%. However, the data are incomplete. Published data mention neuromuscular blocking agents and antibiotics, mainly penicillin and cefazolin, as the main causes of fatal PA. Reported risk factors for fatal PA vary in different countries. Most frequently occurring comorbidities are obesity, male gender, cardiovascular diseases and ongoing treatment with beta-blockers. However, there are no clues about how these factors interact and the impact of individual risk factors. The pathophysiology of fatal PA is still not completely known. Genetic factors such as deficiency in PAF-acetyl hydrolase and hereditary alpha-tryptasemia, have been reported as modulators of severe anaphylaxis and possible targets for specific treatments. Our review underlines unmet needs in the field of fatal PA. Although we confirmed the need for timely administration of an adequate dose of adrenaline and the proper infusion of fluids, there is no evidence-based data on the proper dose of intravenous titrated adrenaline and which clinical manifestations would flag the need for fluid therapy. There are no large clinical studies supporting the administration of alternative vasopressors, such as glucagon and methylene blue. Further research on pathophysiological mechanisms of PA and its severity may address these issues and help clinicians to define new therapeutic approaches.

Population-based incidence of all-cause anaphylaxis and its development over time: a systematic review and meta-analysis

Introduction

It is extremely difficult to compare studies investigating the frequency of anaphylaxis making it challenging to satisfactorily assess the worldwide incidence rate. Using a systematic review and meta-analysis, this publication aims to determine the current incidence of all-cause anaphylaxis worldwide. Additionally, we investigated whether the incidence of anaphylaxis has changed over time and which factors influence the rates determined by individual studies.

Methods

A literature search was performed in four databases. All articles that reported relevant information on population-based incidence rates of all-cause anaphylaxis were included. The protocol was published on INPLASY, the International Platform of Registered Systematic Review and Meta-analysis Protocols.

Results

The database query and screening process resulted in 46 eligible articles on anaphylaxis. The current incidence worldwide was found to be approximately 46 cases per 100,000 population per year (95% CI 21-103). Evaluating confounding factors showed that studies using allergy clinics and hospitalizations as data source result in comparably low rates. Moreover, children are less prone to develop anaphylaxis compared to the general population. Using a random effects Poisson model we calculated a yearly increase of anaphylaxis incidence by 7.4% (95% CI 7.3-7.6, p < 0.05).

Discussion

This seems to be the first approach to analyze every reported all-cause anaphylaxis incidence rate until 2017 for an at most accurate determination of its epidemiology. Based on these results, future research could investigate the underlying causes for the rising incidence in order find ways to decrease the condition's frequency.

Systematic Review Registration

inplasy.com, identifier [INPLASY202330047].