Implementation of anaphylaxis management guidelines

Anaphylaxis management guidelines recommend the use of intramuscular adrenaline in severe reactions, complemented by antihistamines and corticoids; secondary prevention includes allergen avoidance and provision of self-applicable first aid drugs. Gaps between recommendations and their implementation have been reported, but only in confined settings. Hence, we analysed nation-wide data on the management of anaphylaxis, evaluating the implementation of guidelines. Within the anaphylaxis registry, allergy referral centres across Germany, Austria and Switzerland provided data on severe anaphylaxis cases. Based on patient records, details on reaction circumstances, diagnostic workup and treatment were collected via online questionnaire. Report of anaphylaxis through emergency physicians allowed for validation of registry data. 2114 severe anaphylaxis patients from 58 centres were included. 8% received adrenaline intravenously, 4% intramuscularly; 50% antihistamines, and 51% corticoids. Validation data indicated moderate underreporting of first aid drugs in the Registry. 20% received specific instructions at the time of the reaction; 81% were provided with prophylactic first aid drugs at any time. There is a distinct discrepancy between current anaphylaxis management guidelines and their implementation. To improve patient care, a revised approach for medical education and training on the management of severe anaphylaxis is warranted

Implementation of Anaphylaxis Management Guidelines: A Register-Based Study

BACKGROUND: Anaphylaxis management guidelines recommend the use of intramuscular adrenaline in severe reactions, complemented by antihistamines and corticoids; secondary prevention includes allergen avoidance and provision of self-applicable first aid drugs. Gaps between recommendations and their implementation have been reported, but only in confined settings. Hence, we analysed nation-wide data on the management of anaphylaxis, evaluating the implementation of guidelines. METHODS: Within the anaphylaxis registry, allergy referral centres across Germany, Austria and Switzerland provided data on severe anaphylaxis cases. Based on patient records, details on reaction circumstances, diagnostic workup and treatment were collected via online questionnaire. Report of anaphylaxis through emergency physicians allowed for validation of registry data. RESULTS: 2114 severe anaphylaxis patients from 58 centres were included. 8% received adrenaline intravenously, 4% intramuscularly; 50% antihistamines, and 51% corticoids. Validation data indicated moderate underreporting of first aid drugs in the Registry. 20% received specific instructions at the time of the reaction; 81% were provided with prophylactic first aid drugs at any time. CONCLUSION: There is a distinct discrepancy between current anaphylaxis management guidelines and their implementation. To improve patient care, a revised approach for medical education and training on the management of severe anaphylaxis is warranted

Post-Operative Functional Outcomes in Early Age Onset Rectal Cancer

Background: Impairment of bowel, urogenital and fertility-related function in patients treated for rectal cancer is common. While the rate of rectal cancer in the young (<50 years) is rising, there is little data on functional outcomes in this group. Methods: The REACCT international collaborative database was reviewed and data on eligible patients analysed. Inclusion criteria comprised patients with a histologically confirmed rectal cancer, <50 years of age at time of diagnosis and with documented follow-up including functional outcomes. Results: A total of 1428 (n=1428) patients met the eligibility criteria and were included in the final analysis. Metastatic disease was present at diagnosis in 13%. Of these, 40% received neoadjuvant therapy and 50% adjuvant chemotherapy. The incidence of post-operative major morbidity was 10%. A defunctioning stoma was placed for 621 patients (43%); 534 of these proceeded to elective restoration of bowel continuity. The median follow-up time was 42 months. Of this cohort, a total of 415 (29%) reported persistent impairment of functional outcomes, the most frequent of which was bowel dysfunction (16%), followed by bladder dysfunction (7%), sexual dysfunction (4.5%) and infertility (1%). Conclusion: A substantial proportion of patients with early-onset rectal cancer who undergo surgery report persistent impairment of functional status. Patients should be involved in the discussion regarding their treatment options and potential impact on quality of life. Functional outcomes should be routinely recorded as part of follow up alongside oncological parameters

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Analysis of causes, risk factors and medical care of patients with anaphylaxis

Die Anaphylaxie stellt eine schwere, potenziell lebensbedrohliche systemische Hypersensitivitätsreaktion dar. Da die Inzidenzraten von Anaphylaxien weltweit zunehmen und es für den deutschsprachigen Raum nur wenig Daten gibt, wurde 2006 das Anaphylaxie-Register initiiert. Mit dem Register und angegliederten Projekten werden auftretende Anaphylaxien analysiert mit dem Ziel, die Versorgung von Anaphylaxie-Patienten zu verbessern. Dem Register sind allergologische Fachzentren aus Deutschland, Österreich und der Schweiz angeschlossen. Die Meldung anaphylaktischer Reaktionen erfolgt über einen passwort-geschützten Online-Fragebogen. Parallel zu dieser Erhebung wurden im Berliner Raum mittels Papierfragebogen die Notärzte zur Anaphylaxie befragt. Die Analyse der Daten im Meldezeitraum von 2006 bis 2010 zeigte, dass im deutschsprachigen Raum bei Erwachsenen Insektengifte, insbesondere Wespengift, und bei Kindern und Jugendlichen Nahrungsmittel, vorrangig Erdnüsse am häufigsten zur Anaphylaxie führten. Als möglicher Kofaktor spielte bei Kindern und Jugendlichen vor allem die körperliche Anstrengung eine Rolle. Bei Erwachsenen wurden als mögliche Kofaktoren am häufigsten Medikamente, speziell die Beta-Blocker registriert. Ein hohes Alter wurde als Risikofaktor identifiziert, bei einer Anaphylaxie vorrangig mit kardiovaskulären Symptomen zu reagieren. Weiterhin ergab die Risikoanalyse, dass die Entwicklung respiratorischer Symptome begünstigt wird, wenn die Anaphylaxie durch Nahrungsmittel ausgelöst wird und atopische Erkrankungen vorliegen. Im Notfall wurde eine unzureichende Versorgung mit Adrenalin deutlich, was die Notwendigkeit von Schulungsmaßnahmen der behandelnden Ärzte unterstreicht. Die Erhebung zeigt, dass das Anaphylaxie-Register ein wichtiges Instrument zur Analyse von Anaphylaxien im deutschsprachigen Raum darstellt. Es sollte weitergeführt werden, um weitere Kenntnisse zur Anaphylaxie zu erlangen und vor allem um eingeleitete Verbesserungsmaßnahmen zur Versorgung des Patienten beurteilen zu können.Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction. The incidence rates of anaphylaxis are increasing worldwide but only few data is available in the German speaking area. Therefore, an anaphylaxis registry was initiated in 2006. The registry and associated projects analyse anaphylactic reactions with the aim to improve the medical care of patients with anaphylaxis. The data of anaphylactic reactions are obtained using a password-protected online questionnaire by medical centres specialised in allergy from Germany, Switzerland and Austria. Parallel to the online survey emergency physicians from Berlin provided data via a paper questionnaire. The analysis of data from 2006 until 2010 showed that the main causes of anaphylaxis in the German-speaking area among adults were venom related, especially wasp stings whereas in children and adolescents the main causes were food related, mainly peanuts. Possible augmentation factors in adults were drugs, in particular beta-blockers were commonly reported. Among children and adolescents physical exercise was the most common registered augmentation factor. An increasing age was identified as risk factor to develop primarily cardiovascular symptoms during anaphylaxis. The risk analysis also revealed a higher likelihood for the development of respiratory symptoms if the reaction is caused by food and if patients have a concomitant atopic disease. Furthermore, an insufficient use of adrenaline during an emergency became an obvious reported problem during the treatment of anaphylactic patients. This highlights training needs of physicians treating patients with anaphylaxis. The anaphylaxis registry is an important tool for the analysis of anaphylaxis in German speaking countries. It should be continued to gain further knowledge of anaphylaxis and particularly to evaluate whether introduced measures led to an improved medical care of patients

Triggers and Treatment of Anaphylaxis An Analysis of 4000 Cases From Germany, Austria and Switzerland

Background: Anaphylaxis is the most severe manifestation of a mast cell-dependent immediate reaction and may be fatal. According to data from the Berlin region, its incidence is 2-3 cases per 100 000 persons per year. Methods: We evaluated data from the anaphylaxis registry of the German-speaking countries for 2006-2013 and data from the protocols of the ADAC air rescue service for 2010-2011 to study the triggers, clinical manifestations, and treatment of anaphylaxis. Results: The registry contained data on 4141 patients, and the ADAC air rescue protocols concerned 1123 patients. In the registry, the most common triggers for anaphylaxis were insect venom (n = 2074; 50.1%), foods (n = 1039; 25.1%), and drugs (n = 627; 15.1%). Within these groups, the most common triggers were wasp (n = 1460) and bee stings (n = 412), legumes (n = 241), animal proteins (n = 225), and analgesic drugs (n = 277). Food anaphylaxis was most frequently induced by peanuts, cow milk, and hen's egg in children and by wheat and shellfish in adults. An analysis of the medical emergency cases revealed that epinephrine was given for grade 3 or 4 anaphylaxis to 14.5% and 43.9% (respectively) of the patients in the anaphylaxis registry and to 19% and 78% of the patients in the air rescue protocols. Conclusion: Wasp and bee venom, legumes, animal proteins, and analgesic drugs were the commonest triggers of anaphylaxis. Their relative frequency was age-dependent. Epinephrine was given too rarely, as it is recommended in the guidelines for all cases of grade 2 and above

Drugs used for emergency treatment of anaphylaxis, by age.

<p>Dashed lines indicate proportion of patients having received inhalation (adrenaline) or oral (antihistamine, corticoid) treatment only, error bars indicate 95% confidence intervals.</p

First time receiving prophylactic first aid drugs following severe anaphylaxis.

<p>First time receiving prophylactic first aid drugs following severe anaphylaxis.</p

Patients in anaphylaxis registry, first aid treatment stratified by general characteristics and reaction circumstances.

<p>Patients in anaphylaxis registry, first aid treatment stratified by general characteristics and reaction circumstances.</p