Soon after commencement of the penicillin infusion he develops signs of generalised erythema and some mild periorbital oedema.
The nurse stops the infusion and calls for immediate review and advice.
On Examination: BP 150/90, p=120, saO2= 98%. There is no wheeze or stridor. However, he complains of nausea and has vomited once.
QUESTIONS:
1. How severe is this reaction? – ie.grade 1,2,3?
2. Outline your management of this patient, would you give adrenaline? by which route? what dose?
The following links and images may assist you with your answer:
Circulation Journal review on cardiac arrest management
Anonymous Trainee Replied :
ReplyDeleteMy assessment would be that the patient is suffering from a Grade 1 reaction. I note that he has had 1 episode of vomiting, however my understanding is that if he has significant GI involvement, that abdominal cramping and vomiting is often a persistent symptom. In this case, his one off vomit may be a result of his ongoing sepsis (or may herald the start of a Grade 2 anaphylaxis)
He is currently not hypotensive, but is tachycardic and would appear to not be suffering from any respiratory compromise. His tachycardia may be due to his underlying pneumonia/sepsis. (can I ask for a temperature?)
May I also ask for any relevant past medical history i.e. cardiac Hx, respiratory Hx especially Asthma, current medications, allergies?
At face value, I wouldn't give him Adrenaline at this stage as I don't think his reaction is severe enough. But he does have potential for further and rapid decline
Issues at this stage are:
1. Grade 1 Allergic reaction - given the onset soon after the penicillin, that would have to be high up on the list of causes. i.e. Immediate Hypersensitivity.
2. Ongoing Pneumonia (severe enough to require IV ABx) +/- Associated Sepsis
Plan:
1. DRSABC - Although he looks "stable" at this stage, I would still call a MET call, just to have the MET Trolley on hand (I don't think there are Adrenaline mini jets on the ward) as he has the potential for rapid progression of his Sx. However I wouldn't give him Adrenaline at his stage.
2. Cease ongoing Penicillin administration
3. Regular 10min obs (BP/HR/SpO2/Respiratory effort) - In reality I think the reviewing doctor would end up spending at least 30mins-45mins with this patient assessing the situation and this would allow some time for close observation
4. Given the potential for a anaphylactic reaction, I would probably give him an antihistamine e.g. Loratadine or Cetrizine as a stat dose
5. He will need a Tryptase sent
6. Given the immediate hypersensitivity he has displayed, I would also want to change his ABx to Moxifloxacin (provided he's not allergic to this as well).
7. Documentation on the drug chart under allergies for immediate hypersensitivity to penicillins
8. If one hasn't been done already, I would like an ECG just to rule out a concurrent arrhythmia which may complicate issues later.
Anonymous Trainee replied:
ReplyDeletePresumably im present at the MET call...
Definitely i'll give him IV hydrocortisone 100 mg, with oral ranitidine 150mg if he can swallow. High flow oxygen.
I'll then review his airway to make sure there's no swelling.
Check serum tryptase level asap.
Adrenaline will be required as periorbital oedema. I dont think i'll wait and observe as it's better to avoid airway compromise and treat him first...I'll give him intramuscular adrenaline injection according to AMH guideline.... 0.5mg stat
I've recently attended a similar MET call for anaphylactic reaction to **** chemotherapy for **********. At that time 100mcg IV adrenaline given, but ICU team was already there to give support. If im there with MET team only, i dont think i'll give IV adrenaline without ICU registrar present
Anonymous Trainee replied:
ReplyDeleteI was thinking this is probably at least grade 2 anaphylaxis as it is already involving GI and skin (i.e. 2 systems). i'd probably give IV hydrocort as GI absorption is probably not ideal. I would probably also continue it for the next 24-48 hours in case of delayed reaction. I'd also probably try to get him to HDU for close monitoring at least for the first 24 hours if not 48…
Then i'd try to narrow down the culprit although benpen is probably the most likely candidate. i'd be most interested in if he's had benpen or 1st/2nd generation cephalosporins before. If this is his first reaction i'd probably advice for him to avoid penicillins in the future, and extreme caution if he were to receive cephalospirins (although the chances of him having a reaction to newer ones are less compared to 1st/2nd gen).
Dr Jo Thomas replied :
ReplyDeleteThe scenario is intended to describe a possible grade 2 (moderate) anaphylaxis with skin plus GIT involvement. Although I take the point that the 1x vomit may not be sufficient to warrant calling it grade 2, this would be a matter of clinical judgement.
If a grade 2 reaction is suspected clinically adrenaline is appropriate but IM route is recommended. (RAH guidelines are consistent with national guidelines in this regard).
http://circ.ahajournals.org/content/122/18_suppl_3/S829.full
I would discourage initial use of iv adrenaline, particularly when the patient is already tachycardic. You can induce arrythmia, or ischaemia with adrenaline.
If there is a poor initial response to IM adrenaline an intravenous INFUSION is recommended as the next step.
Ranitidine, corticosteroids and antihistamine are appropriate adjuncts BUT should not delay administration of IM adrenaline in a grade 2/3 reaction. Good documentation of the reaction is important, choosing an alternative antibiotic and measuring serum tryptase are all excellent suggestions.
I am not convinced newer cephalosporins are less likely to cause cross reaction in cases of penicillin hypersensitivity.