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Anaphylaxis

Short Text

Assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode.

Introduction

This pathway covers assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode.
Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing, life threatening problems involving: the airway (pharyngeal or laryngeal oedema) and/or breathing (bronchospasm with tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there are associated skin and mucosal changesResuscitation Council (UK) 2008. Emergency treatment of anaphylactic reactions. Guidelines for healthcare providers..
In emergency departments a person who presents with the signs and symptoms listed above may be classified as having a 'severe allergic' reaction rather than an 'anaphylactic' reaction. Throughout the guideline, anyone who presents with such signs and symptoms is classed as experiencing a 'suspected anaphylactic reaction', and should be diagnosed as having 'suspected anaphylaxis'.
After an acute anaphylactic reaction, it is believed that many people do not receive optimal management of their condition. One reason for this is healthcare professionals' lack of understanding when making a diagnosis, for example failing to differentiate anaphylaxis from less severe histamine-releasing reactions or from other conditions that mimic some or all of its clinical features. Another reason is a lack of understanding of when or where to refer patients. This can affect the likelihood of the person receiving a definitive diagnosis, which can lead to anxiety, inappropriate management and recurrent reactions. It can also lead to avoidable costs for the NHS and increase the need for acute care.

Source guidance

The NICE guidance that was used to create the pathway.
Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode. NICE clinical guideline 134 (2011)
Pharmalgen for the treatment of bee and wasp venom allergy. NICE technology appraisal guidance 246 (2012)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Assessment tools

The baseline and self-assessment tools are Excel spreadsheets that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Anaphylaxis: baseline assessment tool

Audit support

Audit support provides ready-to-use criteria, including exceptions, definitions, suggested data sources and a data collection tool.
Anaphylaxis: electronic audit tool
Anaphylaxis: clinical audit tool

Costing support

Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Anaphylaxis: Costing statement
Pharmalgen for the treatment of bee and wasp venom allergy: costing statement

Slide sets

Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Anaphylaxis: Slide set

Pathway information

Information for patients and the public

NICE produces booklets for patients and the public, called 'Understanding NICE guidance'. They summarise, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written a booklet for patients and the public explaining its guidance on anaphylaxis and a leaflet explaining its guidance on Pharmalgen for the treatment of bee and wasp venom allergy.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government. If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.
4 January 2012 Minor maintenance updates.
22 February 2012 Pharmalgen for the treatment of bee and wasp venom allergy (NICE technology appraisal guidance 246) added to Specialist allergy service.
9 March 2012 Minor maintenance updates.

Supporting information

Glossary

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing, life threatening problems involving: the airway (pharyngeal or laryngeal oedema) and/or breathing (bronchospasm with tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there are associated skin and mucosal changes.
After complete recovery of anaphylaxis, a recurrence of symptoms within 72 hours with no further exposure to the allergen. It is managed in the same way as anaphylaxis.
Denotes a form of anaphylaxis where no identifiable stimulus can be found. All known causes of anaphylaxis must be excluded before this diagnosis can be reached.
The diagnosis, prior to assessment by a specialist allergist, for people who present with symptoms of anaphylaxis.
In emergency departments a person who presents with the signs and symptoms of anaphylaxis may be classified as having a 'severe allergic' reaction rather than an 'anaphylactic' reaction. Throughout this guideline, anyone who presents with such signs and symptoms is classed as experiencing a 'suspected anaphylactic reaction', and should be diagnosed as having 'suspected anaphylaxis'.
The diagnosis, prior to assessment by a specialist allergist, for people who present with symptoms of anaphylaxis.
In emergency departments a person who presents with the signs and symptoms of anaphylaxis may be classified as having a 'severe allergic' reaction rather than an 'anaphylactic' reaction. Throughout this guideline, anyone who presents with such signs and symptoms is classed as experiencing a 'suspected anaphylactic reaction', and should be diagnosed as having 'suspected anaphylaxis'.

After emergency treatment for a suspected anaphylactic reaction

After emergency treatment for a suspected anaphylactic reaction

Investigation in adults and young people (16 years or older)

Investigation in adults and young people (16 years or older)

Investigation in adults and young people (16 years or older)

After a suspected anaphylactic reaction in adults or young people aged 16 years or older, take timed blood samples for mast cell tryptase testing as follows:
  • a sample as soon as possible after emergency treatment has started
  • a second sample ideally within 1–2 hours (but no later than 4 hours) from the onset of symptoms.
Inform the person (or, as appropriate, their parent and/or carer) that a blood sample may be required at follow-up with the specialist allergy service to measure baseline mast cell tryptase.

Source guidance

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CG134

Investigation in children (younger than 16 years)

Investigation in children (younger than 16 years)

Investigation in children (younger than 16 years)

After a suspected anaphylactic reaction in children younger than 16 years, consider taking blood samples for mast cell tryptase testing as follows if the cause is likely to be venom-related, drug-related or idiopathic:
  • a sample as soon as possible after emergency treatment has started
  • a second sample ideally within 1–2 hours (but no later than 4 hours) from the onset of symptoms.
Inform the person (or, as appropriate, their parent and/or carer) that a blood sample may be required at follow-up with the specialist allergy service to measure baseline mast cell tryptase.

Source guidance

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CG134

Assessment after the suspected anaphylactic reaction

Assessment after the suspected anaphylactic reaction

Assessment after the suspected anaphylactic reaction

Document the acute clinical features of the suspected anaphylactic reaction (rapidly developing, life-threatening problems involving the airway [pharyngeal or laryngeal oedema] and/or breathing [bronchospasm with tachypnoea] and/or circulation [hypotension and/or tachycardia] and, in most cases, associated skin and mucosal changes).
Record the time of onset of the reaction.
Record the circumstances immediately before the onset of symptoms to help to identify the possible trigger.

Source guidance

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CG134

Observation for adults and young people (16 years or older)

Observation for adults and young people (16 years or older)

Observation for adults and young people (16 years or older)

Adults and young people aged 16 years or older who have emergency treatment for suspected anaphylaxis should be observed for 6–12 hours from the onset of symptoms, depending on their response to emergency treatment. In people with reactions that are controlled promptly and easily, a shorter observation period may be considered provided that they receive appropriate post-reaction care prior to discharge.

Source guidance

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CG134

Admission for children (younger than 16 years)

Admission for children (younger than 16 years)

Admission for children (younger than 16 years)

Children younger than 16 years who have emergency treatment for suspected anaphylaxis should be admitted to hospital under the care of a paediatric medical team.

Source guidance

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CG134

Referral

Referral

Referral

After emergency treatment for suspected anaphylaxis, offer people a referral to a specialist allergy service (age-appropriate where possible) consisting of healthcare professionals with the skills and competencies necessary to accurately investigate, diagnose, monitor and provide on-going management of, and patient education about, suspected anaphylaxis.
Each hospital trust providing emergency treatment for suspected anaphylaxis should have separate referral pathways for suspected anaphylaxis in adults (and young people) and children.

Source guidance

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CG134

Adrenaline injector

Adrenaline injector

Adrenaline injector

After emergency treatment for suspected anaphylaxis, offer people (or, as appropriate, their parent and/or carer) an appropriate adrenaline injector as an interim measure before the specialist allergy service appointment.

Source guidance

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CG134

Patient information and support before discharge

Patient information and support before discharge

Patient information and support before discharge

Before discharge a healthcare professional with the appropriate skills and competencies should offer people (or, as appropriate, their parent and/or carer) the following:
  • information about anaphylaxis, including the signs and symptoms of an anaphylactic reaction
  • information about the risk of a biphasic reaction
  • information on what to do if an anaphylactic reaction occurs (use the adrenaline injector and call emergency services)
  • a demonstration of the correct use of the adrenaline injector and when to use it
  • advice about how to avoid the suspected trigger (if known)
  • information about the need for referral to a specialist allergy service and the referral process
  • information about patient support groups.
NICE has written a booklet for patients and the public explaining its guidance on anaphylaxis.

Source guidance

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CG134

Specialist allergy service

Specialist allergy service

Specialist allergy service

Pharmalgen for the treatment of bee and wasp venom allergy

Pharmalgen is recommended as an option for the treatment of IgE-mediated bee and wasp venom allergy in people who have had:
  • a severe systemic reaction to bee or wasp venom, or
  • a moderate systemic reaction to bee or wasp venom and who have one or more of the following: a raised baseline serum tryptase, a high risk of future stings or anxiety about future stings.
Treatment with Pharmalgen should be initiated and monitored in a specialist centre experienced in venom immunotherapy.
These recommendations are from Pharmalgen for the treatment of bee and wasp venom allergy (NICE technology appraisal guidance 246).
NICE has written a booklet for patients and the public explaining the guidance on Pharmalgen.

Implementation

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Pharmalgen for the treatment of bee and wasp venom allergy: costing statement

Source guidance

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TA246

For children and young people (younger than 19 years) with a food allergy

Children and young people (younger than 19 years) with a food allergy

Food allergy in children and young people pathway

View the 'Food allergy in children and young people overview' path

Paths in this pathway

Pathway created: December 2011 Last updated: March 2012

Copyright © 2012 National Institute for Health and Clinical Excellence. All Rights Reserved.

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