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Biphasic anaphylaxis: A review of the literature and implications for emergency management. [Review]

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Citation: American Journal of Emergency Medicine. 36(8):1480-1485, 2018 08.PMID: 29759531Institution: MedStar Washington Hospital CenterDepartment: Emergency MedicineForm of publication: Journal ArticleMedline article type(s): Journal Article | ReviewSubject headings: *Adrenal Cortex Hormones/tu [Therapeutic Use] | *Anaphylaxis/dt [Drug Therapy] | *Anaphylaxis/pp [Physiopathology] | *Epinephrine/tu [Therapeutic Use] | Emergency Service, Hospital/sn [Statistics & Numerical Data] | Humans | Recurrence | Risk Factors | Time FactorsYear: 2018 Local holdings: Available online from MWHC library: 1995 - present, Available in print through MWHC library: 1999 - 2006ISSN:

0735-6757

Name of journal: The American journal of emergency medicineAbstract: BACKGROUND: The biphasic reaction is a feared complication of anaphylaxis management in the emergency department (ED). The traditional recommended ED observation time is 4-6h after complete resolution of symptoms for every anaphylaxis patient. However, there has been great controversy regarding whether this standard of care is evidence-based.CONCLUSIONS: There is a need for further research to identify true risk factors associated with biphasic anaphylaxis and to clearly define the role of corticosteroids in biphasic reactions. However, given the low incidence and rare mortality of biphasic reactions, patients who receive epinephrine within one hour of symptom onset and who respond to epinephrine with rapid and complete symptom resolution can probably be discharged from the ED with careful return precautions and education without the need for prolonged observation.Copyright (c) 2018 Elsevier Inc. All rights reserved.METHODS: Articles were selected using a PubMed, MEDLINE search for the keywords "biphasic anaphylaxis", yielding 155 articles. Articles were filtered by English language, and the keyword biphasic in the title. Case reports and case series were excluded, narrowing to 33 articles. Then, articles were filtered by relevance to the ED setting, and studies conducted in outpatient clinic settings were excluded, narrowing the search to 16 articles. All remaining articles were reviewed and findings were discussed.RESULTS: The reported mean time to onset between the resolution of initial anaphylaxis and biphasic reaction ranges widely by study from 1 to 72h with the majority of studies reporting the mean time to onset >8h. A delay between anaphylaxis symptom onset and administration of epinephrine of 60-190min was reported to correlate with biphasic anaphylaxis in three studies. Anaphylaxis requiring >1 dose of epinephrine to achieve symptom resolution was also reported to correlate with biphasic reactions in two studies. No definitive conclusions about the role of corticosteroids in preventing biphasic reactions can be made at this time however; a couple small studies have shown that they may decrease the incidence of biphasic reactions. Additional risk factors correlated with biphasic reaction vary widely between studies and the generalizability of these risk factors is questionable.All authors: Mazer-Amirshahi M, Pourmand A, Robinson C, Syed WFiscal year: FY2019Fiscal year of original publication: FY2018Digital Object Identifier:

https://dx.doi.org/10.1016/j.ajem.2018.05.009

Date added to catalog: 2018-06-19

Holdings ( 1 )
Title notes ( 7 )

Holdings
Item type	Current library	Collection	Call number	Status	Date due	Barcode
Journal Article	MedStar Authors Catalog	Article	29759531	Available		29759531

Available online from MWHC library: 1995 - present, Available in print through MWHC library: 1999 - 2006

BACKGROUND: The biphasic reaction is a feared complication of anaphylaxis management in the emergency department (ED). The traditional recommended ED observation time is 4-6h after complete resolution of symptoms for every anaphylaxis patient. However, there has been great controversy regarding whether this standard of care is evidence-based.

CONCLUSIONS: There is a need for further research to identify true risk factors associated with biphasic anaphylaxis and to clearly define the role of corticosteroids in biphasic reactions. However, given the low incidence and rare mortality of biphasic reactions, patients who receive epinephrine within one hour of symptom onset and who respond to epinephrine with rapid and complete symptom resolution can probably be discharged from the ED with careful return precautions and education without the need for prolonged observation.

METHODS: Articles were selected using a PubMed, MEDLINE search for the keywords "biphasic anaphylaxis", yielding 155 articles. Articles were filtered by English language, and the keyword biphasic in the title. Case reports and case series were excluded, narrowing to 33 articles. Then, articles were filtered by relevance to the ED setting, and studies conducted in outpatient clinic settings were excluded, narrowing the search to 16 articles. All remaining articles were reviewed and findings were discussed.

RESULTS: The reported mean time to onset between the resolution of initial anaphylaxis and biphasic reaction ranges widely by study from 1 to 72h with the majority of studies reporting the mean time to onset >8h. A delay between anaphylaxis symptom onset and administration of epinephrine of 60-190min was reported to correlate with biphasic anaphylaxis in three studies. Anaphylaxis requiring >1 dose of epinephrine to achieve symptom resolution was also reported to correlate with biphasic reactions in two studies. No definitive conclusions about the role of corticosteroids in preventing biphasic reactions can be made at this time however; a couple small studies have shown that they may decrease the incidence of biphasic reactions. Additional risk factors correlated with biphasic reaction vary widely between studies and the generalizability of these risk factors is questionable.

English