Refractory Anaphylaxis 2021

Question 1

When would you start following refractory anaphylaxis guidelines?

Answer 1

No improvement in respiratory / cardiovascular symptoms despite 2 appropriate doses of IM adrenaline

Question 2

First steps in refractory anaphylaxis guidelines

Answer 2

1. Seek expert help early
2. Establish IV or IO access

Question 3

Management of refractory anaphylaxis

Answer 3

Give rapid IV fluid bolus + start adrenaline infusion

Question 4

What adrenaline infusion do you use in refractory anaphylaxis

Answer 4

Follow local protocol

OR

1mg adrenaline (1:1000) in 100ml of 0.9% NaCl (in a dedicated line)
- start 0.5 - 1ml/kg/hour
- titrate to response
- do not piggy back onto another infusion
- do not infuse on same side as BP (due to extravasation risk)

Question 5

Increased BP in anaphylaxis is likely to indicate

Answer 5

Adrenaline overdose

Question 6

Until adrenaline infusion has started, what is the management in refractory anaphylaxis

Answer 6

Give IM adrenaline every 5 mins

Question 7

Blood samples are needed for

Answer 7

Mast Cell Tryptase

Question 8

Refractory anaphylaxis treatment of airway

Answer 8

1. Nebulised adrenaline (5ml of 1mg/ml)

Question 9

Refractory anaphylaxis treatment of breathing

Answer 9

1. Oxygen
2. Bag mask ventilation +/- intubation

Question 10

Refractory anaphylaxis treatment of severe/persistent bronchospasm

Answer 10

1. Nebulised salbutamol + ipratropium
2. IV bolus salbutamol / aminophylline

Question 11

Refractory anaphylaxis treatment of circulation

Answer 11

Titrated IV fluid boluses
Child: 10ml/kg per bolus
Adult: 500-1000ml per bolus

Glucose free crystalloid (e.g. Hartmann’s solution / Plasma Lyte).

Question 12

Refractory anaphylaxis when refractory to adrenaline infusion

Answer 12

Noradrenaline
Vasopressin
Metaraminol

Consider glucagon if on beta-blockers