The experience of Zhongshan Hospital tells you that the rescue of allergies: hormones are not the first-line drugs!

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Iodine contrast allergy is not uncommon in cardiac interventional therapy. In order to correct common misunderstandings in the treatment of anaphylactic shock, the author combined this with Zhongshan Hospital's treatment experience and the latest information to write this article for readers for clarification. Fifteen years ago, he participated in a domestic cardiovascular conference, one of which was "successfully managing 1 case of anaphylactic shock caused by iodine contrast agents." The operator attributed his "success" to "high-dose glucocorticoids." My "three points of view" shook for the first time. Later, I heard similar views at many meetings, as if hormone therapy for anaphylactic shock has become the mainstream consensus in China, and I am completely speechless. Iodine contrast allergy is not uncommon in cardiac interventional therapy. In order to correct common misunderstandings in the treatment of anaphylactic shock, the author combined this with Zhongshan Hospital's treatment experience and the latest information to write this article for readers for clarification. In view of the principle of practicality, this article is presented in the form of a question and answer. Why Q: Adrenaline is preferred? All guidelines related to allergic reactions clearly state that adrenaline is a first-line and life-saving drug [1,2]. [3] There are no absolute contraindications. The importance of adrenaline cannot be overemphasized! Once an allergic reaction is diagnosed, it should be administered immediately and as soon as possible. Because all clinical observation studies, randomized controlled studies, retrospective studies, animal experiments and in vitro experiments have clearly told us that the preferred drug for allergic reactions is epinephrine, not glucocorticoids, or antihistamines. Why is adrenaline preferred? Allergic reactions are systemic diseases involving the skin, mucous membranes, respiratory tract, digestive tract, cardiovascular and other organs. The most serious consequences are hypovolemic shock and airway obstruction. For individuals, there is no specific sequence of allergic reactions involving organs, and the progression of the disease cannot be predicted. Therefore, once an allergic reaction is found, priority should be given to drugs with comprehensive effects. Hormones can alleviate bronchospasm, but they have no therapeutic effect on allergic reactions that have already occurred and can only be used to prevent allergic reactions. Hormones and promethazine (phenazine) only relieve skin symptoms and are not effective against fatal hypotension and airway obstruction. Adrenaline can basically meet this need. The full effect of epinephrine's anti-allergic response is shown in the following aspects (Figure 1): α1 adrenergic receptor (α1 receptor) excites, most of the body's organs (except skeletal muscle) produce vasoconstriction, prevent and relieve airway obstruction caused by mucosal edema, prevent and relieve hypotension shock; β1 adrenergic Receptors (β1 receptors) are stimulated to produce positive muscle strength and positive time-varying effects, and relieve hypotension. β2 adrenergic receptors (β2 receptors) are activated, which reduces the release of allergic mediators and relaxes the bronchi. △ Figure 1 "Total curative effect" of epinephrine anti-allergic response: Low epinephrine utilization is also a common problem in clinical practice at home and abroad [4, 5]. About 20 fatal allergic reactions occur in the UK each year. Prior to cardiac and respiratory arrest, epinephrine use was only 14%, compared with 62% overall use [4]. Why Q: Hormones and deception are not first-line treatments? The basis for A: second-line drugs for allergic reactions is mainly from other diseases, such as urticaria (antihistamines) and acute asthma (β2 receptor agonists and glucocorticoids). Due to the lack of clinical trials, recommendations for antihistamines, glucocorticoids, and β2 receptor agonists are inconsistent in various allergy guidelines and reviews. The effectiveness of antiallergic treatments in the context of shock remains controversial. More importantly, over-emphasis on second-line drugs can affect the timely use of first-line drugs. According to the experience of treating acute asthma, hormones can be used to treat allergic reactions, but in fact, their effects are greatly overestimated. (1) No effect on allergic reactions. Hormones are often mistakenly used as first-line drugs, which objectively affects the timely use of adrenaline, a true first-line drug [6]. (2) It can relieve the symptoms of late allergies and prevent bipolar allergies. However, the fact is that these theoretical effects have never been proven, and meta-analysis has yet to prove that glucocorticoids are effective in treating allergic reactions. Even prophylactic intravenous antihistamines or hormones The basis of second-line drugs is mainly from other diseases, such as urticaria (antihistamines) and acute asthma (β2 receptor agonists and glucocorticoids). Due to the lack of clinical trials, recommendations for antihistamines, glucocorticoids, and β2 receptor agonists are inconsistent in various allergy guidelines and reviews. The effectiveness of antiallergic treatments in the context of shock remains controversial. More importantly, over-emphasis on second-line drugs can affect the timely use of first-line drugs. According to the experience of treating acute asthma, hormones can be used to treat allergic reactions, but in fact, their effects are greatly overestimated. (1) No effect on allergic reactions. Hormones are often mistakenly used as first-line drugs, which objectively affects the timely use of adrenaline, a true first-line drug [6]. (2) It can relieve the symptoms of late allergies and prevent bipolar allergies. However, the fact is that these theoretical effects have never been proven, and meta-analysis has yet to prove that glucocorticoids are effective in treating allergic reactions. Even prophylactic intravenous antihistamines or hormones The basis of second-line drugs is mainly from other diseases, such as urticaria (antihistamines) and acute asthma (β2 receptor agonists and glucocorticoids). Due to the lack of clinical trials, recommendations for antihistamines, glucocorticoids, and β2 receptor agonists are inconsistent in various allergy guidelines and reviews. The effectiveness of antiallergic treatments in the context of shock remains controversial. More importantly, over-emphasis on second-line drugs can affect the timely use of first-line drugs. According to the experience of treating acute asthma, hormones can be used to treat allergic reactions, but in fact, their effects are greatly overestimated. (1) No effect on allergic reactions. Hormones are often mistakenly used as first-line drugs, which objectively affects the timely use of adrenaline, a true first-line drug [6]. (2) It can relieve the symptoms of late allergies and prevent bipolar allergies. However, the fact is that these theoretical effects have never been proven, and meta-analysis has yet to prove that glucocorticoids are effective in treating allergic reactions. Even prophylactic intravenous antihistamines or hormones

Intravenous glucocorticoids can take several hours to work, which is why prophylactic allergic hormones should be used earlier than 1 hour. Recommendation: Glucocorticoids can only be injected after epinephrine injection. 2H1 antihistamine Histamine Histamine Histamine is an important mediator of allergic reactions. H1 antihistamines (such as phenanthrene 12.5 ~ 25 mg, intramuscular injection (referred to as intramuscular injection)) can effectively relieve the symptoms of allergic reactions to the skin and mucous membranes, such as pruritus, congestion, urticaria, angioedema, nasal mucus and Conjunctival congestion [8]. However, it cannot cover all the pathophysiological processes of allergies. The key is that it cannot prevent or alleviate the most severe and fatal symptoms such as upper airway obstruction, hypotension and shock. Therefore, H1 antihistamines are not life-saving Drugs are not a substitute for epinephrine. Due to the lack of evidence in randomized controlled trials, some guidelines do not recommend H1 antihistamines for allergy treatment [9, 10]. Compared with epinephrine, H1 antihistamines have a slower effect ( The maximum blood drug concentration is 1 to 3 hours, and epinephrine is less than 10 min [11], and there are potential central nervous system side effects (such as lethargy and cognitive impairment). H2 antihistamines are used in combination with H2 antihistamines Based on H1 antihistamines, it may help relieve congestion, headaches, and other symptoms. [12] However, only a few guidelines recommend H2 antihistamines. Rapid intravenous cimetidine may worsen hypotension [ 13] while ranitidine May cause allergies [14]. There are methodological problems in related clinical trials, and the evidence is insufficient [15, 16]. 4β2 receptor agonists are inferred based on experience in the treatment of acute asthma. Selective β receptor agonists ( (Such as salbutamol) can be used as an adjuvant therapy for allergic reactions to relieve symptoms that adrenaline cannot alleviate, such as wheezing, coughing, shortness of breath, etc. Although these drugs help relieve lower respiratory symptoms, they are due to their minimal α1 receptor effect (Vasoconstrictive effect), they can not prevent or alleviate laryngeal edema, upper airway obstruction, hypotension and shock, so they cannot replace adrenaline. Suggestions for use: Large doses of budesonide aerosol can effectively relieve airway spasm, it is recommended for asthma Use. Q: When will epinephrine be injected? In theory, if the patient has only angioedema or urticaria, oral or intravenous antihistamines can control skin symptoms. If the patient has only asthma, respiratory symptoms can be controlled by inhaling a beta 2 agonist. If the patient continues to have nausea, vomiting or abdominal pain, or have symptoms of the cardiovascular system, intramuscular epinephrine should be considered. However, all guidelines warn that adrenaline should be given as soon as possible after a diagnosis of an allergic reaction. why? In other words, even if the patient does not have hypotension, the adrenaline should be injected intramuscularly [17]! The author analyzed the reasons and summarized them as follows: The unpredictable allergic reaction during the allergic reaction is a systemic disease involving skin, mucous membrane, respiratory tract, digestive tract, cardiovascular and other organs (Table 1). As for a person, there is no specific combination or specific sequence of the organs involved, and it is impossible to predict whether it will develop into a fatal shock [18]! More generally, who knows if rash and asthma are the end or starting point of an allergic reaction? The patient developed a rash after using a cardiac intervention contrast agent. Who can guarantee that patients will not develop hypotension shock? If you take risks, using second-line drugs first will be a big bet. There are also some patients with bipolar allergic reactions: after the symptoms have resolved, they will relapse within 1-72 hours (usually within 8-10 hours), although they will no longer be exposed to allergens [19]. Therefore, once an allergic reaction is diagnosed or highly suspected, do not take risks. Adrenaline. To prevent recurrence, it is best to observe in the hospital for 48 hours [19]. ○ Table 1 Grades of severity of allergic reactions [20] 2 Allergic reactions progress rapidly Fatal allergic reactions The median time from onset to cardiac and respiratory arrest is: food allergy 30 minutes, insect bites 15 minutes, parenteral drugs 5 minutes 4]. The sooner symptoms appear, the more severe the disease, and the worse the prognosis, [21]. The severe allergic reaction left us a short rescue time. It can be said that "there is no time to wait, and no more will come." Epinephrine immediately after rapid injection An unpredictable allergic reaction during an allergic reaction is a systemic disease involving a variety of organs such as skin, mucous membranes, respiratory tract, digestive tract, and cardiovascular (Table 1). As for a person, there is no specific combination or specific sequence of the organs involved, and it is impossible to predict whether it will develop into a fatal shock [18]! More generally, who knows if rash and asthma are the end or starting point of an allergic reaction? The patient developed a rash after using a cardiac intervention contrast agent. Who can guarantee that patients will not develop hypotension shock? If you take risks, using second-line drugs first will be a big bet. There are also some patients with bipolar allergic reactions: after the symptoms have resolved, they will relapse within 1-72 hours (usually within 8-10 hours), although they will no longer be exposed to allergens [19]. Therefore, once an allergic reaction is diagnosed or highly suspected, do not take risks. Adrenaline. To prevent recurrence, it is best to observe in the hospital for 48 hours [19]. ○ Table 1 Grades of severity of allergic reactions [20] 2 Allergic reactions progress rapidly Fatal allergic reactions The median time from onset to cardiac and respiratory arrest is: food allergy 30 minutes, insect bites 15 minutes, parenteral drugs 5 minutes [ 4]. The sooner symptoms appear, the more severe the disease, and the worse the prognosis, [21]. The severe allergic reaction left us a short rescue time. It can be said that "there is no time to wait, and no more will come." Epinephrine immediately after rapid injection An unpredictable allergic reaction during an allergic reaction is a systemic disease involving a variety of organs such as skin, mucous membranes, respiratory tract, digestive tract, and cardiovascular (Table 1). As for a person, there is no specific combination or specific sequence of the organs involved, and it is impossible to predict whether it will develop into a fatal shock [18]! More generally, who knows if rash and asthma are the end or starting point of an allergic reaction? The patient developed a rash after using a cardiac intervention contrast agent. Who can guarantee that patients will not develop hypotension shock? If you take risks, using second-line drugs first will be a big bet. There are also some patients with bipolar allergic reactions: after the symptoms have resolved, they will relapse within 1-72 hours (usually within 8-10 hours), although they will no longer be exposed to allergens [19]. Therefore, once an allergic reaction is diagnosed or highly suspected, do not take risks. Adrenaline. To prevent recurrence, it is best to observe in the hospital for 48 hours [19]. ○ Table 1 Grades of severity of allergic reactions [20] 2 Allergic reactions progress rapidly Fatal allergic reactions The median time from onset to cardiac and respiratory arrest is: food allergy 30 minutes, insect bites 15 minutes, parenteral drugs 5 minutes [ 4]. The sooner symptoms appear, the more severe the disease, and the worse the prognosis, [21]. The severe allergic reaction left us a short rescue time. It can be said that "there is no time to wait, and no more will come." Epinephrine immediately after rapid injection

How to use Q: Adrenaline? A: Usage: Once an allergic reaction is diagnosed or highly suspected (even if the blood pressure is normal!), 0.01 mg / kg (concentration 1: 1000, 1 mg / ml) of epinephrine is injected into the anterolateral thigh muscles. The maximum dose is 0.5 mg for adults and 0.3 mg for children. For out-of-hospital allergic patients, the European guidelines even encourage patients to intramuscularly epinephrine to save themselves (Figure 2) [2, 22]! Ask yourself, if the allergy to iodine contrast agent occurs in the catheter lab, why not give adrenaline? △ Figure 2 Self-administration of epinephrine [23] intramuscular injection can quickly reach peak plasma and tissue concentrations, which is better than subcutaneous injection [24]. If the response is not good, the injection can be repeated every 5-15 minutes until the symptoms are relieved or symptoms of hyperadrenal function (pallor, tremor, anxiety, palpitations, dizziness, headache, etc.) occur. )occur. Most patients need only one or two intramuscular injections, and a few patients need more than two. However, it should be applied flexibly in some special cases: if shock is imminent or has already occurred, slow intravenous injection of epinephrine is required. If cardiac arrest is imminent or has already occurred, epinephrine needs a rapid intravenous injection. However, in general, intravenous epinephrine should avoid allergic reactions [25]. Any epinephrine administration route produces a transient drug response (hyperadrenal symptoms including paleness, tremor, anxiety, palpitations, dizziness, headache, etc.). ), Indicating that the therapeutic dose has been reached. Severe side effects caused by excessive adrenaline include ventricular arrhythmias, hypertension crisis, and pulmonary edema. This usually occurs during intravenous injections. For example, the intravenous injection is too fast and the concentration is too high (1: 1000 or 0.1 mg / ml for intravenous injection and 1: 1000 or 1 mg / ml for intramuscular injection). Q: What about ineffective adrenaline (refractory allergy)? There is no doubt that A: epinephrine will be used first, but a few patients have no or insufficient response to intramuscular epinephrine injection. For these patients with refractory hypotension shock, the following treatments should be performed when analyzing the cause (Table 2): (1) Elevation of the lower limbs in the supine position; (2) Active intravenous fluid resuscitation; intravenous injection of 20 ml / kg crystal solution and restoration of circulating blood volume are prerequisites for adrenaline to exert its therapeutic effect. (3) Drug boosters and device boosters; commonly used antihypertensive drugs include norepinephrine, dopamine, dobutamine, norepinephrine and vasopressin. There are no clinical trials to compare which is better or worse. There is no standard dose, the dose is adjusted based on clinical response, and blood pressure, heart rate, heart function, and oxygenation are closely monitored. If the dose is too large and undetectable, fatal serious adverse events may occur, such as ventricular arrhythmias, hypertension crisis, and pulmonary edema [1]. In addition, we have successfully rescued cases of aortic balloon counterpulsation (IABP) [26, 27], as well as cases of extracorporeal membrane oxygenation combined with IABP [28, 29]. (4) Oxygen inhalation, tracheal intubation, and cardiopulmonary resuscitation preparation; tracheal intubation: Patients often have edema of the throat and tracheal mucosa, and even a large amount of mucus covers the upper airway anatomical landmarks. Tracheal intubation is somewhat difficult, and it is best to have an experienced doctor perform the operation. It is helpful to pre-oxygenate for 3 to 4 minutes before tracheal intubation. ○ Table 2 Causes of ineffective adrenaline (refractory allergy) acute coronary syndrome: acute coronary syndrome; ACEI: angiotensin converting enzyme inhibitor interaction between cardiovascular disease and allergic reaction (1) heart Vascular disease increases the risk of severe or fatal allergic reactions; some cardiovascular drugs, including beta blockers and ACEI, can also exacerbate allergic reactions, making them difficult to treat. (2) In allergic reactions, cardiac mast cells release histamine, leukotriene, platelet activating factor (PAF), and other mediators, which in turn induce coronary artery spasm and acute myocardial infarction (Kaunis syndrome) [30]. (3) Emergency drugs such as epinephrine have significant cardiovascular effects and cause potential risks such as ventricular arrhythmias, hypertension crisis, and acute coronary syndromes. However, when allergic reactions become the main contradiction, it should be kept in mind that there are no absolute contraindications to the use of adrenaline [3]. Factors related to iodine-containing contrast agent allergy are often considered physical problems Patients often experience edema of the throat and tracheal mucosa, and even a large amount of mucus covers the upper airway anatomical landmarks. Tracheal intubation is somewhat difficult, and it is best to have an experienced doctor perform the operation. It is helpful to pre-oxygenate for 3 to 4 minutes before tracheal intubation. ○ Table 2 Causes of ineffective adrenaline (refractory allergy) acute coronary syndrome: acute coronary syndrome; ACEI: angiotensin converting enzyme inhibitor interaction between cardiovascular disease and allergic reaction (1) heart Vascular disease increases the risk of severe or fatal allergic reactions; some cardiovascular drugs, including beta blockers and ACEI, can also exacerbate allergic reactions, making them difficult to treat. (2) In allergic reactions, cardiac mast cells release histamine, leukotriene, platelet activating factor (PAF), and other mediators, which in turn induce coronary artery spasm and acute myocardial infarction (Kaunis syndrome) [30]. (3) Emergency drugs such as epinephrine have significant cardiovascular effects and cause potential risks such as ventricular arrhythmias, hypertension crisis, and acute coronary syndromes. However, when allergic reactions become the main contradiction, it should be kept in mind that there are no absolute contraindications to the use of adrenaline [3]. Factors related to iodine-containing contrast agent allergy are often considered physical problems Patients often experience edema of the throat and tracheal mucosa, and even a large amount of mucus covers the upper airway anatomical landmarks. Tracheal intubation is somewhat difficult, and it is best to have an experienced doctor perform the operation. It is helpful to pre-oxygenate for 3 to 4 minutes before tracheal intubation. ○ Table 2 Causes of ineffective adrenaline (refractory allergy) acute coronary syndrome: acute coronary syndrome; ACEI: angiotensin converting enzyme inhibitor interaction between cardiovascular disease and allergic reaction (1) heart Vascular disease increases the risk of severe or fatal allergic reactions; some cardiovascular drugs, including beta blockers and ACEI, can also exacerbate allergic reactions, making them difficult to treat. (2) In allergic reactions, cardiac mast cells release histamine, leukotriene, platelet activating factor (PAF), and other mediators, which in turn induce coronary artery spasm and acute myocardial infarction (Kaunis syndrome) [30]. (3) Emergency drugs such as epinephrine have significant cardiovascular effects and cause potential risks such as ventricular arrhythmias, hypertension crisis, and acute coronary syndromes. However, when allergic reactions become the main contradiction, it should be kept in mind that there are no absolute contraindications to the use of adrenaline [3]. Factors related to iodine-containing contrast agent allergy are often considered physical problems

This is also related to the repeated use of iodine contrast agents. Fujiwara N. et al. [32] retrospectively analyzed the relationship between repeated use of contrast agents and allergic reactions in 1729 patients with liver cancer, showing a U-shaped curve. However, due to the frequent use of contrast agents, there is little reference in the cardiovascular field. 2. Patient Attributes After intravenous angiography of patients using β-blockers and ACEI, the risk of allergic reactions is not only increased, but the condition is more serious [33]. Once anaphylactic shock occurs, the prognosis is extremely poor and often fatal [34]. Women are more susceptible to IV contrast allergy and have more severe reactions [35]. The difference between hypersensitivity, allergic reaction and allergic reaction △ Figure 3 Difference between hypersensitivity reaction, allergic reaction and allergic reaction [36] Although allergic reaction and allergic reaction are synonyms, they all refer to the first type of hypersensitivity reaction, in general In usage, an allergic reaction usually refers to an acute allergic reaction with a potentially fatal risk, such as the conversion of anaphylactic shock to anaphylactic shock instead of anaphylactic shock. Contrast allergy undoubtedly meets the original intention of allergic reactions, although it is clinically impossible to distinguish between allergic reactions (IgE-mediated) or allergic reactions (non-IgE-mediated). Abstract-For allergic reactions to contrast agents, intramuscular epinephrine is the first-line treatment, while hormones are only the second-line treatment. For anaphylactic shock, adrenaline is a first-line treatment, while booster-based large-volume fluid infusion is a second-line treatment. Hormones are just third-line therapy! Source: China Medical Forum Yisheng University welcomes nurse-related original articles. Please read the nursing book in detail, and click "Read Original" below to select and purchase.