The Journal of Allergy and Clinical Immunology: In Practice
Original ArticleEpinephrine in Anaphylaxis: Higher Risk of Cardiovascular Complications and Overdose After Administration of Intravenous Bolus Epinephrine Compared with Intramuscular Epinephrine
Section snippets
Study design
We conducted an observational cohort study of patients who presented to the ED from April 2008 through July 2012.
Setting and participants
This study was conducted at Mayo Clinic Hospital, Saint Marys campus ED, a tertiary care academic ED that has a patient volume of 73,000 annual patient visits, including both pediatric and adult patients of all ages. Patients who presented with anaphylaxis as defined per the National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network diagnostic criteria
Results
The study cohort included 573 patients, of whom, 301 (57.6%) received at least 1 dose of epinephrine (Table I). Overall, 341 patients were women (60%) and the median age was 34.5 years (interquartile range, 18.6-51.5 years). A total of 362 doses of epinephrine were administered to 301 patients: 245 IM autoinjector (67.7%), 71 IM injection (19.6%), 30 SC injection (8.3%), 12 IV bolus (3.3 %), and 4 IV continuous infusion (1.1%). There was no difference by sex, age, or race in the frequency of
Discussion
To our knowledge, this is the first study to systematically compare the risk of CV complications and overdose with various routes of epinephrine administration for anaphylaxis. We found a significantly higher risk of CV complications (10% vs 1.3%) and overdose (13.3% vs 0%) with IV bolus epinephrine compared with IM epinephrine administration. In addition, our results confirmed the relative safety of IM epinephrine administration. Although numerous case reports have established the link between
Conclusions
Our results underscore the risks associated with the use of IV bolus epinephrine in the management of anaphylaxis. Furthermore, they demonstrate the relative safety of the use of the IM autoinjector, given that overdose is much less likely with this design and that there were no associated major CV adverse events. When taken together, these findings support current guidelines that recommend initial use of IM epinephrine and avoidance of IV bolus epinephrine except in extreme circumstances.
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Cited by (0)
No funding was received for this work.
Conflicts of interest: The authors declare that they have no relevant conflicts of interest.