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Editor,—We have read with grave concern the project team's recommendations for the medical treatment of anaphylaxis1 and believe very strongly that the advice against using intravenous adrenaline (epinephrine) is potentially very dangerous. We also find the omission of reference to guidelines for the management of anaphylaxis in the accident and emergency (A&E) department published in the same journal2 as very regrettable if deliberate, or puzzling if the project team had no knowledge of their existence.
The project team's guidelines have also failed to emphasise the relevance of grading the severity of anaphylaxis and that its treatment should be directed to the severity of the attack encountered.
We agree that the project team's guidelines should be used by the inexperienced and invariably pre-hospital responders. We also agree that the subcutaneous route is unreliable and should be abandoned. However, to suggest that A&E seniors or supervised trainees and well supported juniors lack clinical credibility to administer high dilution intravenous epinephrine carefully titrated against response in the fully monitored patient in the resuscitation room is insulting to the specialty of A&E. It also shows that in spite of having A&E representation the project team fails to understand fundamental principles of A&E involvement in the management of the critically ill.
To suggest that patients with clinical signs of shock should be administered intramuscular epinephrine as epinephrine can be rapidly absorbed is in physiological terms most bizarre advice.
We conclude that the project team's guidelines need urgent revision as they will lead to patients dying due to failure to urgently administer intravenous epinephrine. We will continue, as we hope the majority of A&E departments will do similarly, to use the published A&E guidelines2 and we believe that they are currently the best available guidelines for treating anaphylaxis in the A&E department.
Professor Chamberlain replies on behalf of the Anaphylaxis Project Team
We are grateful to Dr Brown for his kind general remarks about our consensus guidelines, and also for giving us the opportunity to clarify one sentence in our introduction. We said “There has been a vogue for inappropriate use of intravenous epinephrine (adrenaline), both by paramedics and in accident and emergency departments, when epinephrine (adrenaline) should have been given intramuscularly”. We believe this to be true, but it was most certainly not our intention to condemn all use of intravenous adrenaline by experienced medical practitioners either in emergency departments or elsewhere. In retrospect we see that we should have been more explicit on this point. We agree totally with Dr Brown's statement that adverse outcomes for adrenaline occur when it has been given too rapidly, inadequately diluted, or in excessive dosage. We also recognise that emergency medicine has progressed a long way in the last decade with a much higher level of senior supervision and greater possibilities for treatment under monitored conditions.
Our guidelines were intended specifically for those first medical responders who are inexperienced in the management of this emergency. They are unlikely to have monitoring facilities available. For these, cautious recommendations are appropriate with intravenous use of adrenaline restricted to emergencies judged to be immediately life threatening.
The examples that we gave for indications for intravenous adrenaline were clearly not intended to be comprehensive, and experienced physicians in monitored areas will appropriately make their own decisions. We did mention the value of infusions of 1:100 000 adrenaline which permits titration of dose against need. It may also be worth emphasising that in asphyxia from upper airway oedema and hypoxia from severe bronchospasm, there are additional priorities—not replacing parenteral adrenaline—such as oxygenation and nebulised inhaled bronchodilators. Dr Brown's comments do, of course, add to our own guidelines by making sound recommendations for expert management that was outside the remit of our article.
The concerns of Mr Gavalas and his colleagues were similar, but there seems also to be an element of misreading of our document. They say that they “believe very strongly that the advice against using intravenous adrenaline (epinephrine) is potentially very dangerous”. We must reiterate that we did not advise against its use, but urged only that it should be used in the most serious cases and by experienced clinicians.
Our guidelines stated in paragraph 4.4 that:
“Intravenous epinephrine (adrenaline) in a dilution of at least 1:10 000... is hazardous and must be reserved for patients with profound shock that is immediately life threatening and for special indications”.
We also added in paragraph 5.2:
“The use of epinephrine (adrenaline) by the intravenous route in the special circumstances given in paragraph 4.4 should usually be reserved for medically qualified personnel who have experience of it, who know that it must be administered with extreme care, and who are aware of the hazards associated with its use”.
The footnote to the legends state very clearly:
“Consider slow intravenous (IV) ephinephrine (adrenaline) 1:10 000 solution. This is hazardous and is recommended only for an experienced practitioner who can also obtain IV access without delay”.
There are some practitioners who have made the habit of always using adrenaline intravenously, while others have preferred the subcutaneous route, and many are afraid to give it at all. We believe that we have given the correct emphasis—that intramuscular adrenaline is the norm for the emergency treatment by first medical responders, with IV adrenaline reserved for special and life threatening situations. This is far from advising against its use!
There is one charge to which we must plead guilty. Of course we were aware of the previous paper published in the Journal of Accident & Emergency Medicine in 1998, and it was indeed our intention to reference it together with the other specialist recommendations. That omission was not deliberate, and one of us (DAC) must take responsibility for that important last minute oversight.
We do not accept that the guidelines need urgent revision. Neither does the Project Team with its wide representation accept that the recommendations as they stand are insulting to the specialty of accident and emergency. We are conscious that we all have the same aims: better and safer treatment of an important medical emergency.
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