pituitrin and Anaphylaxis

Anaphylaxis is a time-sensitive, clinical diagnosis that is often misdiagnosed because the presenting signs and symptoms are similar to those of other disease processes. This issue reviews the criteria for diagnosing a pediatric patient with anaphylaxis and offers evidence-based recommendations for first- and second-line treatment, including the use of epinephrine, antihistamines, and corticosteroids. Guidance is also provided for the appropriate disposition of patients with anaphylaxis, including prescribing epinephrine autoinjectors and offering training on how to use them, educating patients and families on avoidance of known offending allergens, and referring the patient to a specialist in allergy and immunology. [Points & Pearls is a digest of Pediatric Emergency Medicine Practice.]

Topics: Anaphylaxis; Bronchodilator Agents; Child; Critical Pathways; Diagnosis, Differential; Early Diagnosis; Emergency Medical Services; Emergency Service, Hospital; Epinephrine; Extracorporeal Membrane Oxygenation; Humans; Medical History Taking; Physical Examination; Risk Factors; Vasopressins

Topics: Anaphylaxis; Child; Crystalloid Solutions; Fluid Therapy; Hemodynamics; Humans; Isotonic Solutions; Shock; Shock, Cardiogenic; Shock, Septic; Vasopressins

Topics: Anaphylaxis; Animals; Corticotropin-Releasing Hormone; Cytokines; Hypersensitivity; Immune System; Paraventricular Hypothalamic Nucleus; Pituitary Gland, Posterior; Pituitary Hormones, Anterior; Rats; Rats, Brattleboro; Vasopressins

Topics: Adrenocorticotropic Hormone; Adult; Alkalosis, Respiratory; Anaphylaxis; Animals; Cardiovascular Diseases; Collagen Diseases; Gastrointestinal Diseases; Gonadotropins; Hematologic Diseases; Hormones, Ectopic; Humans; Hypoxia; In Vitro Techniques; Infant, Newborn; Lung; Lung Diseases; Lung Neoplasms; Microscopy, Electron; Neuromuscular Diseases; Neurotransmitter Agents; Paraneoplastic Endocrine Syndromes; Pulmonary Edema; Pulmonary Embolism; Pulmonary Emphysema; Rats; Respiratory Distress Syndrome, Newborn; Skin Diseases; Syndrome; Vasopressins

The two life-threatening signs of anaphylactic shock (AS) are severe arterial hypotension and bronchospasm. Guidelines recommend epinephrine as first-line treatment. Arginine vasopressin (AVP) has been proposed as an alternative if epinephrine does not correct arterial hypotension. These two drugs may have beneficial, neutral or deleterious effects on airflow either directly or by modifying factors that regulate vasodilatation and/or edema in the bronchial wall.. To compare the effects of epinephrine and AVP on airflow and airway leakage in a rat model of AS.. Thirty-two ovalbumin-sensitized rats were randomized into four groups: control (CON), AS without treatment (OVA), AS treated with epinephrine (EPI), and AS treated with AVP (AVP). Mean arterial pressure (MAP), respiratory resistance and elastance and microvascular leakage in the airways were measured.. All OVA rats died within 20 minutes following ovalbumin injection. Ovalbumin induced severe arterial hypotension and airway obstruction (221 ± 36 hPa.s.L. Epinephrine was superior to AVP for alleviating the airway response in a rat model of AS. When bronchospasm and severe arterial hypotension are present during AS, epinephrine should be the drug of choice.

Topics: Airway Obstruction; Anaphylaxis; Animals; Arterial Pressure; Bronchial Spasm; Capillary Leak Syndrome; Epinephrine; Hypotension; Neurophysins; Ovalbumin; Protein Precursors; Rats; Respiratory System; Vasopressins

Anaphylactic shock is sometimes life-threatening, but the defense system against this circulatory failure was not fully understood. Ameliorating roles of angiotensin (ANG) II and vasopressin in anaphylactic hypotension were investigated in anesthetized ovalbumin-sensitized Sprague-Dawley rats. The sensitized rats were randomly allocated to the following pretreatment groups (n=7/group): (1) control (non-pretreatment), (2) ANG II synthesis inhibitor captopril, (3) ANG II receptor antagonist losartan, and (4) V1a vasopressin receptor antagonist. Anaphylactic shock was induced by an intravenous injection of the antigen. The systemic arterial pressure (SAP), central venous pressure (CVP), portal venous pressure (PVP) and portal venous blood flow (PBF) were measured, and splanchnic vascular resistance (Rspl: (SAP-PVP)/PBF) was determined. In the control group, SAP markedly decreased, followed by a gradual recovery toward baseline. Rspl transiently decreased immediately after antigen, and then increased 1.5-fold at 15 min and thereafter. The pretreatment with either losartan, captopril or V1a receptor antagonist augmented the initial fall of SAP and attenuated the SAP recovery along with augmentation of the late increase in Rspl. The 2-h survival rate was significantly smaller in either pretreatment group than in the control group (100%). Plasma levels of ANG II and vasopressin increased to 3.8- and 9.8-fold, respectively, at 30 min after antigen in the control group, whereas captopril pretreatment inhibited the increase in ANG II. In conclusion, inhibition of ANG II or vasopressin exacerbates anaphylaxis-induced hypotension in anesthetized rats.

Topics: Anaphylaxis; Anesthesia; Angiotensin II; Animals; Blood Pressure; Captopril; Hemodynamics; Male; Rats; Rats, Sprague-Dawley; Vasopressins

Hemodynamic instability may occur during liver transplantation especially following unclamping the portal vein. A period of hypotension (postreperfusion syndrome) is usually responsive to treatment with fluids, calcium, sodium bicarbonate, and vasoactive drugs, but if hypotension persists, other causes must be sought out. In this report, we present a case in which anaphylaxis, most likely due to a component of the University of Wisconsin preservation solution, occurred coincident with liver reperfusion and severely exacerbated reperfusion hemodynamic instability. To our knowledge, this is the first report of anaphylaxis at the time of reperfusion and may provide an explanation for cases of vasoplegic syndrome associated with graft reperfusion.

Topics: Alcoholism; Anaphylaxis; Bile; Blood Pressure; Dopamine; Hepatitis C, Chronic; Humans; Liver Transplantation; Male; Middle Aged; Phenylephrine; Reperfusion Injury; Respiration, Artificial; Treatment Outcome; Vasopressins

Topics: Anaphylaxis; Anesthesia; Humans; Vasoconstrictor Agents; Vasopressins

To report the use of vasopressin to treat a patient who, after failing to respond to volume expansion and epinephrine administration, experienced an anaphylactic reaction to rocuronium.. A 17-yr-old female was scheduled to undergo transnasal, transsphenoidal resection of a pituitary tumour. Shortly after induction of general anesthesia, for which rocuronium 50 mg iv was administered to facilitate tracheal intubation, the patient developed severe hypotension and diffuse erythema. This severe,allergic response was refractory to the administration of intravenous fluids, epinephrine, and phenylephrine. However, arginine vasopressin, administered intravenously as a bolus of two units, followed by an infusion of 2 U.hr(-1), rapidly corrected the hemodynamic instability. Her recovery from this episode was uneventful, but surgery was cancelled. Skin testing, performed six weeks later, was positive for rocuronium and negative for cisatracurium and latex, as well as all other medications administered. Eight weeks later, the surgical procedure was performed, uneventfully, using cisatracurium as the muscle relaxant.. Vasopressin may be effective in the resuscitation of anesthetized patients, with hemodynamic instability associated with anaphylaxis resistant to epinephrine and alpha-agonists.

Topics: Adolescent; Anaphylaxis; Androstanols; Female; Humans; Neuromuscular Nondepolarizing Agents; Rocuronium; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Severe anaphylaxis can be associated with cardiovascular collapse that is difficult to manage and does not respond to treatment with epinephrine. Because anaphylaxis is uncommon, unpredictable and may be fatal, a prospective, randomized, controlled trial in humans on the best management is difficult and guidelines are based on theory and anecdotes only.. We report six cases in which the use of vasopressin was successful in the treatment of anaphylactic shock.. Standard treatment of anaphylactic shock, including discontinuation of the causative agent, administration of epinephrine, and infusion of IV fluids, did not stabilize cardiocirculatory function, and adding arginine vasopressors resulted in prompt hemodynamic stabilization.

Topics: Aged; Anaphylaxis; Epinephrine; Female; Humans; Intraoperative Complications; Male; Middle Aged; Vasoconstrictor Agents; Vasopressins

Severe anaesthetic anaphylaxis is relatively uncommon. Oxygen, fluids and epinephrine are considered to be the mainstay for treatment of cardiovascular collapse and current guidelines for the management of anaphylaxis list only epinephrine as a vasopressor to use in the event of a cardiovascular collapse. Recently, evidence has emerged in the support of the use of vasopressin in cardiopulmonary resuscitation; it is also recommended for the treatment of ventricular fibrillation, septic shock and post-cardiopulmonary bypass distribution shock. Currently, there is no algorithm or guideline for the management of anaphylaxis that include the use of vasopressin. We report a 24-year-old woman who developed severe anaphylactic shock at induction of anaesthesia while undergoing laparoscopic cholecystectomy. Circulation shock was refractory to epinephrine and high doses of pure alpha-agonist phenylephrine and norepinephrine. Single intravenous dose of two units of vasopressin re-established normal circulation and blood pressure.

Topics: Adult; Algorithms; Anaphylaxis; Blood Pressure; Catecholamines; Cholecystectomy; Drug Resistance; Epinephrine; Female; Humans; Norepinephrine; Phenylephrine; Treatment Outcome; Vasoconstrictor Agents; Vasopressins

Topics: Anaphylaxis; Disease Management; Gelatin; Humans; Vasopressins

Recent studies demonstrate that vasopressin is useful when treating hemorrhagic and septic shock. The effect of vasopressin on systemic anaphylaxis has not been investigated except in clinical case reports. Vasopressin increases blood pressure because of vasoconstriction through the V1 receptor. Thus, we evaluated the effect of vasopressin on circulatory depression and bronchoconstriction provoked by systemic anaphylaxis and survival rates in rabbits. In the first set of experiments, 15 nonsensitized rabbits received normal saline (control) and vasopressin at 0.8 or 0.08 U/kg. In the second set, 40 sensitized rabbits received horse serum to induce anaphylaxis, and then received the same drugs as in the first set. In the first set, mean arterial pressure (MAP) in vasopressin groups increased by 18% to 24% compared with the control. Vasopressin at 0.8 U/kg decreased MAP insignificantly before the increases of MAP occurred. In the second set, vasopressin at 0.08 U/kg improved the survival rate. At 45 min after antigen challenge, 69% of the rabbits that received vasopressin at 0.08 U/kg were alive, whereas 29% of the control rabbits and 23% of the rabbits that received vasopressin at 0.8 U/kg were alive. Vasopressin increased MAP by 36% to 109% compared with the control within 5 min, however, at 2 min, vasopressin at 0.8 U/kg had no effect on MAP. Pulmonary dynamics were similar. In conclusion, vasopressin at 0.08 U/kg improved survival rates and severe hypotension provoked by systemic anaphylaxis, suggesting that this agent may be useful in the treatment of systemic anaphylaxis.

Topics: Anaphylaxis; Animals; Blood Pressure; Electrocardiography; Female; Hemodynamics; Hypotension; Male; Rabbits; Shock, Septic; Temperature; Time Factors; Treatment Outcome; Vasoconstriction; Vasoconstrictor Agents; Vasopressins

Topics: Anaphylaxis; Epinephrine; Female; Humans; Middle Aged; Vasopressins

Anaphylactic shock therapy includes the use of catecholamines but they may not always be effective. Because vasodilation during anaphylaxis is a result of the endothelial release of multiple mediators, we investigated the effects of epinephrine, vasopressin, and inhibitors of nitric oxide and prostanoid pathways on histamine-induced relaxation in human internal mammary artery. The vessel segments were obtained intraoperatively and were suspended in organ chambers to record isometric tension. Norepinephrine (10(-6) M) was used to precontract the rings followed by histamine (10(-6.5) M) to relax the vessels and mimic vascular collapse. Epinephrine, vasopressin, methylene blue, N(G)-monomethyl-L-arginine (L-NMA) and indomethacin were added in a cumulative fashion to reverse the histamine-induced vasodilation. The internal mammary artery segments exhibited greater contraction in the presence of the epinephrine (4.9 +/- 0.7 g) compared with vasopressin (2.6 +/- 0.7 g). Vasopressin (10(-11) to 10(-7) M), methylene blue (10(-7) to 10(-5) M), L-NMA (10(-6) to 10(-4) M), and indomethacin (10(-7) to 10(-5) M) were only partially effective. These findings suggest that vasopressin and methylene blue may offer a potential therapeutic option in the treatment of histamine-induced vasodilatory shock.. Epinephrine only partially reverses histamine-induced vasodilation in human internal mammary arteries, whereas vasopressin, methylene blue, and drugs involved in the inhibition of nitric oxide and prostaglandin generation lead to a complete reversal of the vascular relaxation.

Topics: Adrenergic Agonists; Anaphylaxis; Cyclooxygenase Inhibitors; Enzyme Inhibitors; Epinephrine; Guanylate Cyclase; Histamine; Humans; In Vitro Techniques; Indomethacin; Mammary Arteries; Methylene Blue; omega-N-Methylarginine; Vasodilation; Vasodilator Agents; Vasopressins

The degree to which pulmonary angiography may contribute to serious complications in patients with pulmonary hypertension has not been clarified and remains a matter of debate. Accordingly, this study was designed (1) to detect the potential release of vasoactive peptides and (2) to investigate the hemodynamic response after administration of a nonionic contrast medium in patients with pulmonary hypertension undergoing pulmonary angiography. Allergy-mediating substances also were measured to monitor for possible anaphylactoid reactions.. Pulmonary digital subtraction angiography was performed in 20 patients with pulmonary hypertension (mean pulmonary arterial pressure more than 20 mm Hg). Iopromide was administered as a total of 100 mL via a 7F catheter inserted from the right femoral vein. The injected volume and duration of injection (15 to 20 mL/sec) were kept constant. Hemodynamic parameters were continuously monitored, including electrocardiogram, heart rate, phasic and mean pulmonary arterial and peripheral arterial pressures. Blood samples were obtained before and after administration of contrast media to assay for the concentration of the following vasoactive peptides using radioimmunoassay techniques: renin, angiotensin-I-converting enzyme, angiotensin II, aldosterone, atrial natriuretic peptide, antidiuretic hormone, cyclic-guanosine monophosphate, and myoglobin, as well as allergy-mediating substances such as tryptase, eosinophil protein X, and eosinophil cationic protein.. Administration of iopromide caused significant increases in atrial natriuretic peptide (from 61.3 +/- 11.8 to 94.0 +/- 16.7) and antidiuretic hormone (from 6.6 +/- 1.9 to 12.3 +/- 3.1), whereas renin significantly decreased (from 3.0 +/- 0.6 to 1.3 +/- 0.5). After administration of contrast media, there were no significant changes in the other measured vasoactive peptides, allergy-mediating substances, and monitored cardiovascular parameters.. Administration of iopromide for pulmonary angiography in patients with pulmonary hypertension resulted in no appreciable hemodynamic alterations associated with the observed changes in atrial natriuretic peptide, antidiuretic hormone, and renin. No allergy-mediated reactions were observed in these patients.

Topics: Adult; Aged; Aldosterone; Anaphylaxis; Angiography, Digital Subtraction; Angiotensin II; Atrial Natriuretic Factor; Blood Pressure; Blood Proteins; Chymases; Contrast Media; Cyclic GMP; Electrocardiography; Eosinophil Granule Proteins; Eosinophil-Derived Neurotoxin; Female; Heart Rate; Humans; Hypertension, Pulmonary; Inflammation Mediators; Iohexol; Lung; Male; Middle Aged; Myoglobin; Peptides; Peptidyl-Dipeptidase A; Renin; Ribonucleases; Serine Endopeptidases; Tryptases; Vasopressins

In anaphylactic paw edema the reactivity of blood vessels to norepinephrine in the isolated perfused hind legs of rats and mice is reduced. A vasoreactivity depressing factor was postulated and searched for. PAF-acether, histamine and lipoxygenase products were found as being possibly responsible for depression of the vascular reactivity.

Topics: 4,5-Dihydro-1-(3-(trifluoromethyl)phenyl)-1H-pyrazol-3-amine; Alprostadil; Anaphylaxis; Animals; Anti-Inflammatory Agents; Epoprostenol; Female; Histamine; Indomethacin; Inflammation; Male; Mice; Mice, Inbred Strains; Norepinephrine; Platelet Activating Factor; Prostaglandins E; Pyrazoles; Rats; Rats, Inbred Strains; Serotonin; Vasopressins

Topics: Allergens; Anaphylaxis; Animals; Antigen-Antibody Reactions; Child, Preschool; Diabetes Insipidus; Drug Hypersensitivity; Erythrocytes; Hemagglutination Tests; Histiocytosis, Langerhans-Cell; Humans; Immune Sera; Immunization, Passive; Immunochemistry; Immunodiffusion; Immunoglobulin E; Lysine; Male; Oxytocin; Phenylalanine; Sheep; Skin Tests; Vasopressins

Topics: Anaphylaxis; Angiotensin II; Animals; Blood Circulation; Bronchi; Dogs; Guinea Pigs; Histamine; Kinins; Lung; Peptides; Perfusion; Rats; Serotonin; Vasopressins

Topics: Adrenocorticotropic Hormone; Anaphylaxis; Animals; Capillary Permeability; Dextrans; Edema; Female; Growth Hormone; Hypophysectomy; Pituitary Hormones, Anterior; Prolactin; Rats; Stimulation, Chemical; Thyrotropin; Vasopressins

Topics: Acetylcholine; Anaphylaxis; Angiotensin II; Animals; Antimetabolites; Arachidonic Acids; Autacoids; Bradykinin; Chemistry, Organic; Drug Antagonism; Epinephrine; Glucose; Glycosides; Histamine; In Vitro Techniques; Inflammation; Kinins; Mice; Muscle, Smooth; Organic Chemistry Phenomena; Peroxides; Rabbits; Rats; Serotonin; Trypsin; Vasopressins; Venoms

Topics: Anaphylaxis; Animals; Diuresis; Glomerular Filtration Rate; Hyaluronoglucosaminidase; Kidney; Kidney Concentrating Ability; Natriuresis; Rabbits; Vasopressins; Water-Electrolyte Balance

Topics: Adrenal Cortex Hormones; Allergens; Anaphylaxis; Anesthesia; Anesthetics; Drug Hypersensitivity; Drug Therapy; Epinephrine; Geriatrics; Humans; Hypersensitivity; Isoproterenol; Oxygen Inhalation Therapy; Skin Tests; Theophylline; Toxicology; Vasopressins