Dr. Noel Rodríguez Perez,

Alergólogo-Pediatra

Profesor de Pediatría y Alergia Universidad Autónoma de Tamaulipas

drnoel@alergia.ws; www.alergia.ws

XVII Congreso

Latinoamericano de Asma,

Alergia e inmunología

Escolar de 6 años de

edad acude a

urgencias por

picadura de abeja

EF. Edema facial,

urticaria, disnea,

sibilancias, T/A en

limite normal. Estable

Difenhidramina?

Hidrocortisona?

Rehidratación?

Epinefrina?

Intubación?

SABA nebulizado?

1.-Anaphylaxis. J Allergy Clin Immunol 2008;121:S402-7. 2.-Second Symposium on the Definition and Management of Anaphylaxis: Summary Report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis

Network Symposium Ann Emerg Med. 2006;47:373-380.

Anafilaxia, es una reacción alérgica sistémica, de inicio agudo y potencialmente fatal, que ocurre de manera súbita posterior al contacto con una causa conocida de alergia.

Simons RE. J Allergy Clin Immunol 2009;124:625-36.

3 to 6 hours

(CysLTs, PAF,

IL-5)

Mast cell

Allergen

Cellular infiltrates: 3 to 6 hours (LPR)

PGs

Return

of

Symptoms

Histamine IL-4, IL-6

Eosinophil

CysLTs, GM-CSF,

TNF-, IL-1, IL-3, PAF,

ECP, MBP

Proteases

CysLTs

Basophil Histamine,

CysLTs,

TNF-, IL-4, IL-5, IL-

6

Monocyte

CysLTs, TNF-,

PAF, IL-1

Lymphocyte

IL-4, IL-13, IL-5,

IL-3, GM-CSF EPR 15 min (Early-Phase Reaction)

Simons RE. J Allergy Clin Immunol 2009;124:625-36.

Difenhidramina?

Hidrocortisona

Rehidratación?

Adrenalina!

Intubación?

SABA nebulizado?

Adrenalina es el fármaco más eficaz para el tratamiento de la anafilaxia (A)

Aplicar adrenalina ante el primer signo o síntoma de anafilaxia

A-Adrenalina

B-Braething (respiración)

C-Circulación

Mclean-Tooke AP, Bethune CA, Fay AC, Spickett GP. Adrenaline in the treatment of anaphylaxis: what is the evidence?

BMJ 2003; 327:1332-5.

Multicenter study of emergency department visits for food

allergies. Clark S. et al. J Allergy Clin Immunol 2004;113:347-52.

Objetivo: Describir el manejo de reacciones alérgicas agudas por alimentos

Métodos: Revisión de expedientes de 21 departamentos de urgencias EU.

Resultados: 678 expedientes, ~29 años, 57% mujeres, 43% hombres

Tratamiento:

Antihistamínicos: 72%

Corticoesteroides sistémicos: 48%

Epinefrina: 16% (12% referido a alergólogo)

Pumphrey RS. Lessons for management of

anaphylaxis from a study of fatal reactions.

Clin Exp Allergy. 2000 Aug;30(8):1144-50.

Objetivo: Entender las circunstancias que llevan a una

anafilaxia fatal

Métodos. Revisión del registro de todos los casos de

anafilaxia fatal desde 1992.

Expedientes con Información detallada para dar

seguimiento de casos, reacción, necropsia .

Lessons for management of anaphylaxis from a study of fatal reactions.

Pumphrey RS. Clin Exp Allergy. 2000 Aug;30(8):1144-50.

Hallazgos

~20 muertes registradas por año

~50% iatrogénicas, 25% alimentos, 25% veneno de insectos

~50% murieron por asfixia (alimentos) y 50% por choque

(iatrogénico, veneno)

Media tiempo de muerte. 5 min iatrogénico, 15 min veneno, 30

min alimentos

28% resucitados pero murieron 3 horas a 30 días (hipoxia)

La adrenalina se uso en 62%, solo 14% antes del paro cardiaco

Bock SA et al. J Allergy Clin Immunol 2001;107:191-3

80.5

70.2

37.3

12.9

0

10

20

30

40

50

60

70

80

90

Corticosteroids Antihistamines Epinephrine Resuscitation

67.3

18.6 15.2

5.8

0

10

20

30

40

50

60

70

80

Discharged to home Symptomatic/medic Hospitalization Return within 24hs

Muerte por anafilaxia correlaciona con retraso en aplicación de epinefrina.

Debe de administrarse de inmediato ante síntomas respiratorios ó

cardiovasculares.

El uso temprano esta justificado en pacientes con antecedente de asma y

especialmente en aquellos que requieren de medicación frecuente

Epinefrina mantiene T/A, Antagoniza efectos de mediadores, e inhibe

liberación posterior.

No contraindicaciones absolutas

Es la droga de primera elección, es bien tolerada y es potencialmente salva

vidas.

Kemp SF, Lockey RF, Simons RE Allergy 2008: 63: 1061–1070

Intramuscular (IM). (B)

Concentraciones plasmáticas mayores y

más rápidas la vía subcutánea.

Mayor margen de seguridad que la

administración intravenosa.

El mejor sitio de administración es la cara

anterolateral del muslo (B).

Simons FER, Gu X, Simons KJ. J Allergy Clin Immunol 2001; 108:871-3.

Simons FER, Roberts JR, Gu X, Simons KJ. J Allergy Clin Immunol 1998; 101:33-7.

Adultos (1mg = 1ml

1/1.000) 0.3 a 0.5. Repetir

cada 5 a 15 minutos

según la gravedad y

tolerancia del paciente.

Lactantes y niños, 0.01

mg por kilogramo,

máximo 0.3 mg, repetir en

5 a 15 minutos en caso

necesario.

Liberman P, et. al. J Allergy Clin Immunol 2010;126:477-80.

Simons FER. J Allergy Clin Immunol. 2004;113:837-44.

Tiempo para Cmax después de la inyección (minutos)

5 10 15 20 25 30 35

Epinefrina

IM

Epinefrina

Subcutánea 34 ± 14(5-120)

minutos

8 ± 2 min

p<0.05

Simons FR, et al. J Allergy Clin Immunol 2001;108:871-3.

Mutasem M. et al. J Allergy Clin Immunol 2006;117: 398-403.

Potencial de Arritmia letal: Hipotension profunda,

Insuficiencia C-R. Pobre respuesta a dosis repetidas de

epinefrina IM o SC. En UCI/Urgencias

No dosis o rigimen establecio

1:100,000 (1mg [1mL de 1:1000 en 100mL sol. Salina])

Infusion continua de 30 a 100mL/hora (5 a 15mL/minuto): 0.5 a

0.1µg/kg/hora

Niños. Regla de los “6”: 0.6/peso (Kgs) = mcg + cbp 100mL sol.

Sal. (100µg/10ml). Infusion continua a 0.l - 1µg/kg/minuto

IV/intraosea.

Lieberman P. Et al. Allergy Clin Immunol 2010;126:477-80.

Davis JE, et al. Ped Emergency Med 2007;4:1-28

GALAXIA. Med Clin (Barc). 2011 Mar 26;136(8):349-55.

…Sin embargo, no siempre es efectiva:

Administración tardía

Dosis inadecuada

Vía de administración inapropiada

Epinefrina caducada

Enfermedades subyacentes: Asma no controlada,

Enfermedad cardiovascular, Mastocitos

1042 Simons et al J ALLERGY CLIN IMMUNOL

DECEMBER 2001

picking up the syringe to injecting the epinephrine dose

into the vial were as follows: parents, 142 ± 13 seconds

(range, 83-248); physicians, 52 ± 3 seconds (range, 30-

83); general duty nurses, 40 ± 2 seconds (range, 26-71);

and emergency department nurses, 29 ± 0.09 seconds

(range, 27-33). The control groups did not differ signifi-

cantly from each other with regard to speed (P > .05).

The mean (± SEM) volume of epinephrine drawn up by

the parents was 0.07 ± 0.01 mL (range, 0.004-0.151); this

compared with volumes of 0.085 ± 0.01 mL (range, 0.03-

0.19) for the physicians, 0.098 ± 0.01 mL (range, 0.04-

0.13) for the general duty nurses, and 0.099 ± 0.01 mL

(range, 0.07-0.15) for the emergency department nurses.

The mean (± SEM) value for epinephrine content of

the parents’ doses (73 ± 11 mg; range, 4-151) did not dif-

fer significantly from those of the physicians (86 ± 10

mg; range, 25-193), the general duty nurses (98 ± 7 mg;

range, 44-133), or the emergency department nurses (99

± 6 mg; range 72-145; P > .05; Fig 2). There was an

almost 40-fold range of epinephrine content of the doses

drawn up by the parents; this was in contrast to a 7- to 8-

fold range in the physician group, a 3-fold range in the

general duty nurse group, and a 2-fold range in the emer-

gency department nurse group.

There was no correlation between the time that it took

to draw up the epinephrine doses and the amount of the

epinephrine (in micrograms) contained in the doses (Fig

3). The parents’ comments about the technique included

the following:

“It takes too long.”

“The components are small and easy to lose.”

“The amount is tiny, impossible to remember, and

difficult to measure.”

“It is very easy to give an overdose or no dose at all.”

“The removal of the air is the hardest part.”

“This is way too much to ask of a parent.”

“In a real-life emergency, an anxious parent could not

do this.”

“This is far too hard, too complicated, and too difficult

for a parent to do.”

“Babysitters and daycare staff would refuse to do this.”

DISCUSSION

The available options for administration of an accurate

epinephrine dose to infants experiencing anaphylaxis out-

side the hospital setting vary considerably in ease of use

and in cost, and each has advantages and disadvantages.

The EpiPen Jr and EpiPen auto-injectors currently

represent the most user-friendly method of giving an epi-

nephrine injection, but they are also associated with the

greatest expense ($50.00 US or more for a single dose)

and are not available in many countries. They have the

additional disadvantage that neither of the 2 doses avail-

able (0.15 mg for the EpiPen Jr and 0.3 mg for the

EpiPen) is suitable for infants, given that even by the age

of 24 months only 3% of infants will have achieved a

weight of 15 kg.15 The Ana-Kit was intermediate

between the EpiPen Jr and EpiPen auto-injectors and the

FIG 1. The length of time needed for participants to draw up the

epinephrine dose is shown by group. The parents were signifi-

cantly slower (P £ .05) than the controls. During treatment of actu-

al anaphylaxis, when seconds count, this difference might be clin-

ically relevant. The controls did not differ significantly from each

other (P > .05). GD, General duty; ED, emergency department.

FIG 2. The epinephrine content (in micrograms) of the dose drawn

up by the participants is shown by group. Wide variances were

found, from a 40-fold range in epinephrine content of parents’

doses (worst) to a 2-fold range of epinephrine content of emer-

gency department nurses’ doses (best). The mean epinephrine

doses drawn up by each group did not differ significantly (P > .05).

GD, General duty; ED, emergency department.

FIG 3. There was no correlation between the accuracy of the epi-

nephrine dose and the speed with which the dose was drawn up.

It is a concern that some doses fell outside the potential 50%

underdosing (45 mg) and 50% overdosing (135 mg) broad limits

indicated by the shaded areas. MD, Physician; GDN, general duty

nurse; EDN, emergency department nurse.

Tiempo necesario para cargar dosis

correcta de epinefrina.

Padres significativamente lentos VS

control.

Dosis de epinefrina en jeringa.

Rango de ±40 veces en padres VS

±2 en enfermeras

Simons FER, et al. J Allergy Clin Immunol 2000;105:1025-30.

GALAXIA. Med Clin (Barc). 2011 Mar 26;136(8):349-55.

Efectos frecuentes, transitorios:

Ansiedad, miedo, inquietud, mareos, cefalea, palpitaciones, palidez, temblor.

Poco frecuentes, asociados a dosis:

Arritmias ventriculares, isquemia miocárdica, edema pulmonar, crisis de hipertensión, hemorragia intracraneal.

Riesgo aumentado:

Ancianos, morbilidad asociada, MAO, Antidepresivos, Beta bloqueadores, intoxicación cocaína

Aplique epinefrina al inicio de cualquier signo o síntoma

de anafilaxia

Simons FER, et al. Curr Opin Allergy Clin Immunol. 2012;12(4):389-399.