Anaphylaxis:assessment and referral

Implementing NICE guidance

December 2011

NICE clinical guideline 134

What this presentation covers

Background

Scope

Recommendations

Costs and savings

Discussion

NICE Pathway

NHS Evidence

Find out more

Image reproduced with kind permission of Dr Pete Smith, Medicalpix.com

Background

• There are four common triggers – drug, food, latex and insect venom – plus an idiopathic group where the trigger is not known

• Approximately 1 in 1333 of the population of England has experienced anaphylaxis at some point in their lives

• There are approximately 20 deaths from anaphylaxis reported each year in the UK

Scope

This guideline covers adults, young people and children who receive emergency treatment for suspected anaphylaxis.

It covers

•clinical assessment following emergency treatment•provision of adrenaline auto-injectors•referral •information needs and provision

Definitions• Anaphylaxis – a severe, life-threatening, generalised or

systemic hypersensitivity reaction

• Biphasic anaphylaxis – after complete recovery of anaphylaxis, a recurrence of symptoms within 72 hours with no further exposure to the allergen

• Idiopathic anaphylaxis – a form of anaphylaxis where no identifiable trigger can be found

• Recurrence – a return of symptoms as part of the natural progress of a disease

• Suspected anaphylaxis – the diagnosis prior to assessment by a specialist allergist for people who present with symptoms of anaphylaxis

Recommendations

• Clinical assessment after emergency treatment

• Mast cell tryptase testing

• Observation or admittance to hospital (for children)

• Referral

• Discharge

• Referral pathways

• Document the acute clinical features of the suspected anaphylactic reaction

• Record the time of onset of the reaction

• Record the circumstances immediately before the onset of symptoms to help to identify the possible trigger

Clinical assessment after emergency treatment

• In adults or young people 16 years or older take timed blood samples for mast cell tryptase

• In children younger than 16 years consider taking blood samples for mast cell tryptase if the cause is thought to be venom-related, drug-related or idiopathic

• Take– 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

Mast cell tryptase testing

• Adults and young people aged 16 and over should be observed for 6–12 hours from the onset of symptoms

• With appropriate post-reaction care, those whose reactions were controlled promptly and easily, may be observed for a shorter period

• Children under 16 years should be admitted to hospital under the care of a paediatric medical team

Observation

After emergency treatment for suspected anaphylaxis

• Offer a referral to a specialist allergy service (age-appropriate where possible)

• Offer an appropriate adrenaline injector as an interim measure before the specialist allergy service appointment

Referral

Discharge

Before discharge offer

•information about anaphylaxis, including signs and symptoms of an anaphylactic reaction•information about the risk of biphasic reaction•information on what to do if an anaphylactic reaction occurs•a demonstration of use of the adrenalin injector and when to use it•advice regarding avoidance of the suspected trigger (if known)•information about the need for referral to the specialist allergy service and the referral process•information about patient support groups

Referral pathways

Each hospital providing emergency treatment for suspected anaphylaxis should have separate referral pathways for suspected anaphylaxis in adults (and young people) and children

Costs and savings

This guideline is unlikely to result in a significant change in resource use in the NHS

However, recommendations 1.1.9 and 1.1.12, which concern referral to a specialist allergy service following a suspected anaphylactic reaction, may result in additional costs/savings depending on local circumstances

Discussion

• What are the training needs of staff with regards to provision of adrenaline injectors and information for patients?

• What specialist services are available locally for referral, and are referral pathways in place?

• What information do we currently provide to patients who have had an anaphylactic reaction? How does this need to be changed to meet the recommendations in the guideline?

NICE Pathway

The NICE anaphylaxis pathway covers assessment to confirm an anaphylactic reaction and the decision to refer after emergency treatment for a suspected anaphylactic reaction.

Click here to go to NICE Pathways

website

NHS Evidence

Visit NHS Evidence for the best available evidence on all aspects of health and social care.

Click here to go to the NHS Evidence

website

Find out more

Visit www.nice.org.uk/guidance/CG134 for:

•the guideline •‘Understanding NICE guidance’•costing statement•audit support

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