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Refractory Anaphylaxis
- Refractory anaphylaxis is defined as anaphylaxis that does not respond to at least 2 doses of 300 mcg of epinephrine given IM into the anterolateral thigh.
- Refractory anaphylaxis can be due to several factors including patient comorbidities, delayed diagnosis, delayed epinephrine administration, or concomitant beta-blocker or ACE-inhibitor medication use.
- Consider the following treatments in patients with refractory anaphylaxis, persistent hypotension, and shock:
- Aggressive IVF resuscitation - patients may need up to 7L of IVFs
- Epinephrine infusion (1-10 mcg/min) to target a MAP of 65 mm Hg
- Glucagon (1-5 mg via slow IV push) for those taking a beta-blocker and who fail to respond to epinephrine
- Norepinephrine, vasopressin, angiotensin II, methylene blue, or dobutamine can be administered with epinephrine for persistent hypotension.
- VA-ECMO - though there is no prospective evidence on the use of ECMO in anaphylaxis.
References
Krishnaswamy G. Critical care management of anaphylaxis: A conside definitive review. Crit Care Med. 2021.