Characterization of Patients Requiring Multiple Doses of Epinephrine
Abstract
Introduction: The current standard of care for patients experiencing anaphylaxis is an intramuscular injection of epinephrine, with rapid administration being associated with decreased reports of hospitalization and death. One of the feared consequences of anaphylaxis is the progression toward a more severe state, with one of the most cited risk factors for severe anaphylaxis being a delayed administration of epinephrine. However, recent studies looking at the pharmacokinetics of epinephrine show that serum concentrations can vary based on the mode of epinephrine delivery: auto-injectors and manual intramuscular injection. The CHKD Allergy Clinic currently administers epinephrine through both modalities. This data prompted our research project to assess whether there is an impact of utilizing the manual syringe compared to auto-injector on clinical outcomes.
Methods: Retrospective chart review using electronic medical records between 1/1/18 - 12/31/23 with ICD10 code of 96076 (oral food challenge) from the CHKD Allergy & Asthma Clinic. Patients 0 to 65 years old who experienced an episode of anaphylaxis during an oral food challenge and required at least one dose of epinephrine were included. Data was collected on the following: demographics, relevant serum specific IgE levels and skin tests to relevant allergen(s), grade of anaphylaxis according to the Anaphylaxis Grading System, other atopic comorbidities, modality and dose of epinephrine, and additional medications used to treat anaphylaxis.
Results: Out of the 151 administrations of epinephrine given, 29 (19%) received more than 1 dose of epinephrine. Out of the 103 manual administrations of epinephrine given, 18 (17.65%, p=0.06) received more than 1 dose of epinephrine. Out of the 20 auto-injector administrations of epinephrine given, 1 (5.0%, p=0.06) received more than 1 dose of epinephrine.
Conclusion: The rate of receiving more than 1 dose of epinephrine for food-induced reactions (19%) is higher than the national average of 11.1%. Manual administration of epinephrine (17.65%, p=0.06) correlated more with needing a second dose of epinephrine than auto-injector administration (5.0%, p=0.06). This data suggests that auto-injector administration of epinephrine may be preferred for intramuscular injections of epinephrine indicated for anaphylactic reactions to food challenges.