Pharmacist use of the electronic medical record to identify adults at risk for anaphylaxis without epinephrine for self-administration.

OBJECTIVES: To describe an innovative pharmacist-led approach, with the use of electronic medical record (EMR) data, to identify patients at risk of anaphylaxis in need of epinephrine auto-injector (EAI) for self-administration. SETTING: An urban free health care center for an uninsured indigent adult population in Pittsburgh, PA. PRACTICE INNOVATION: In this pilot service, patients with allergy history fields containing the words "anaphylaxis," "nut," "bee," or "shellfish" were screened for inclusion. PRACTICE DESCRIPTION: Patients were identified with the use of a report generated by the EMR vendor and were contacted via telephone by a clinical pharmacist. Using the patient-reported clinical history related to anaphylaxis and allergies, the pharmacist assessed the need for EAI, counseled the patient, and provided physician referral when appropriate. EVALUATION: The service was evaluated with the use of a cross-sectional study of patients with electronic records at the health center during the time period studied. Data obtained from patient interviews were used to classify patients who were candidates for EAI and to assess prescribing and access to EAI. Demographic data and outcomes related to the availability of non-expired EAI were collected and analyzed using descriptive statistics. RESULTS: Ninety-five patients were identified as potential candidates for the service, and 20 patients were able to be contacted via telephone. Fourteen participants provided consent for their data to be used in the program evaluation. A treatment gap likely existed for 11 of the 14 participants (79%) owing to history of anaphylaxis (57%) or history of systemic reaction (29%). The most common indication for EAI was anaphylaxis in response to bee stings. CONCLUSION: The findings from this project demonstrate that pharmacist use of EMR data, coupled with patient interview, may be an effective means for identifying treatment gaps in the long-term management of anaphylaxis and has the potential to ultimately improve management of anaphylaxis in patients within the community.

Anaphylaxis and cardiac surgery for hypertrophic obstructive cardiomyopathy: a case report and review of anaesthetic management.

BACKGROUND: The aim of this paper is to describe clinical management in a situation where patient has experienced anaphylaxis while undergoing surgical septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM). CASE REPORT: A 40-yr-old female was scheduled to undergo surgical septal myectomy for the treatment of HOCM. After induction, the patient developed refractory hypotension that did not respond to escalating doses of vasopressors and volume therapy. Although a clinical examination led to the diagnosis of anaphylaxis, epinephrine, which is the usual treatment of choice, failed to improve the patient's haemodynamics. A transesophageal echocardiography revealed a worsening of left ventricular outflow tract obstruction (LVOTO) after epinephrine administration. In the end, the rapid institution of a cardiopulmonary bypass was required as a rescue therapy instead of to save a patient. CONCLUSION: The anaesthetic goals in a patient in HOCM are to maintain preload and afterload and to avoid stimulation of inotropy and chronotropy to leading to left ventricular outflow obstruction. In a patient with anaphylaxis, maintaining these haemodynamic goals becomes much more difficult since the pathophysiology and usual treatment of choice will worsen LVOTO. Special consideration for the need to have extracorporeal life support to treat refractory hypotension in surgical patients with HOCM may be warranted.

Myocardial infarction in a 45-year-old man following an anaphylactic reaction to a wasp sting.

We present the case of a 45-year-old man with clinical features of acute coronary syndrome with persistent ST segment elevation following an anaphylactic reaction to a wasp sting treated with adrenaline. A thrombolysis is performed with no effect on clinical signs, leading to an emergency cardiac catheterization which reveals a non-occlusive thrombosis of the right coronary artery. The pathophysiology and clinical implications of this association are discussed.

Elevation of alanine transaminase and gallbladder wall abnormalities as biomarkers of anaphylaxis in canine hypersensitivity patients.

OBJECTIVE: The purpose of the study was to evaluate alanine transaminase (ALT) and gallbladder wall abnormalities as possible biomarkers for anaphylaxis in dogs presented for acute hypersensitivity reactions. DESIGN: Pilot study. SETTING: A private practice, small animal, 24-hour emergency and specialty hospital. ANIMALS: Ninety-six dogs presenting 101 times on an emergency basis for hypersensitivity reactions from March 2007 through March 2009. INTERVENTIONS: Veterinarians acquired a history, physical exam, serum chemistry panel, blood pressure, and ultrasound image of the gallbladder. MEASUREMENTS AND MAIN RESULTS: Dogs were then divided into 2 groups: dogs fulfilling the definition for anaphylaxis (moderate and severe systemic hypersensitivity) and dogs that did not fulfill the definition and were classified as allergic reactions (local hypersensitivity and mild systemic hypersensitivity). Elevated ALT was significantly associated with anaphylaxis (P<0.001). Increased gallbladder wall thickness and a striated wall pattern were significantly associated with anaphylaxis (P<0.001) and these changes were readily apparent to first-responder veterinarians. Decreased body temperature (P<0.001) and hypothermia (P=0.006) were significantly associated with anaphylaxis. There was no significant difference between groups regarding age, heart rate, or presence of respiratory signs. Lower blood pressure was significantly associated with anaphylaxis (P<0.001) but hypotension was not significantly different (P=0.09) between groups. Cutaneous signs were significantly associated with the allergic reactions group (P<0.001) and, when seen with anaphylaxis, were subtle. CONCLUSIONS: This study showed an elevated ALT and an abnormal gallbladder wall to be biomarkers significantly associated with anaphylaxis in dogs with acute hypersensitivity reactions.

Midventricular hypokinesis as a cardiac manifestation of anaphylaxis: a case report.

We report a case of anaphylaxis in which left midventricular hypokinesis was found by echocardiogram performed while the patient was hypotensive shortly after the onset of acute chest pain with S-T segment elevations. Cardiac injury was confirmed by elevation of cardiac enzymes. Repeated echocardiogram 2 days later demonstrated normal ventricular wall function and coronary angiogram demonstrated no angiographically apparent disease. We discuss possible mechanisms for cardiac injury and suggest mast cell-mediated coronary spasm as the most likely.

Anaphylaxis after propofol infusion for Port-A-Cath insertion in a 35-year old man.

Anaphylaxis to propofol is rare and has not been previously reported in Asia. We describe a 35-year-old man with nasopharyngeal carcinoma who developed acute respiratory distress and hypotension after propofol infusion for parenteral anesthesia for Port-A-Cath insertion. Chest roentgenogram showed bilateral diffuse alveolar infiltrates. Respiratory failure ensued, and vocal cord swelling was found during endotracheal intubation. Hemodynamic data included a low cardiac index, a low systemic vascular resistance, and a high pulmonary vascular resistance. His condition and the shadows on the chest roentgenogram improved quickly after fluid challenge and the use of vasopressors, antihistamine, and intravenous steroids. Early awareness and appropriate management are necessary to prevent a fatal outcome in patients with propofol anaphylaxis.

Acute colorectal ischaemia after anaphylactoid shock.

A 29 year old woman is reported with bloody diarrhoea three hours after developing anaphylactoid shock. Sigmoidoscopy, barium enema, and histology showed rectal and colonic ischaemia to the splenic flexure. Recovery was complete. There was no history of vascular disease but the patient was taking an oral contraceptive. Thirty one other cases of spontaneous ischaemic proctitis are reviewed.