Anaphylaxis and dosing errors
Medication errors are of particular interest to me, so this paper caught my eye. Here’s my summary of it. It’s a paper by Benkelfat et al and is published in the September 2013 issue of the Journal of Emergency Medicine.
Benkelfat R, Gouin S, Larose G, Bailey B. Medication errors in the management of anaphylaxis in a pediatric emergency department. J Emerg Med. 2013 Sep;45(3):419-25.
It examined the use of standard order forms to reduce medication errors in managing anaphylaxis in paediatric emergencies.
Why was this study needed?
It may seem surprising, but most doctors do not know the correct dose of adrenaline (epinephrine) to give in the management of anaphylaxis.
Tain and Rubython (2007) reported in a New Zealand study that only 20% of doctors knew the correct dose and route of administration of adrenaline for anaphylaxis. And Drost and Narayan (2010) found that only 15% of UK doctors would give adrenaline as recommended by the UK resuscitation guidelines. These studies were all in adults, and one would expect that in children, there would be even more error due to weight variation and low frequency of presentation.
We need to be able to treat anaphylaxis quickly, safely and optimally, as patients can deteriorate rapidly and die from this. And an overdose of adrenaline comes with its own set of side effects.
What was the intervention?
The authors introduced a standard order form (SOF), which was given to doctors when prescribing medications for anaphylaxis (in their Paediatric Emergency Department in Canada).
They then looked at the frequency of medication errors before and after introducing the SOF.
How did they find the patients?
This was done retrospectively by searching for patients coded with anaphylaxis or anaphylactic shock in their ED database. The notes were then cross-checked against the National Institute of Allergy and Infectious Diseases diagnostic criteria for anaphylaxis to ensure the patients actually had anaphylaxis.
How did they decide what constituted an error?
Incorrect medication dosages (10% and 25% margin of error for doses); wrong drug administration; and a delay in administration (15 min delay for adrenaline, 30 min delay for other drugs).
How many patients were included?
96 patients were included – 31 in the Pre-SOF group and 65 in the Post-SOF group. In the Post-SOF group, 30 patients were SOF negative – this means that even though SOF had been introduced in the department, the SOF was not used for those patients.
What did they find?
A whopping 60% of medication charts contained at least one medication error (59% post-SOF).
The number of dosage errors decreased significantly when the SOF was used (this was true for both the 10% and 25% error margins).
Perhaps most importantly for our learning, the correct adrenaline doses for managing anaphylaxis in paediatric emergencies are…
Give IM doses of 1:1000 adrenaline into the lateral thigh (can repeat after 5 mins if not improving).
Avoid subcutaneous administration and do not use IV bolus adrenaline unless cardiac arrest is likely.
Nebulised adrenaline can be used as adjunctive therapy (to IM) but not as 1st line.
Dosing can be 0.01ml/kg of 1 in 1000, or if it is easier to remember:
<6 years old: 150mcg (0.15 mL) IM
6-12 years old: 300mcg (0.3 mL) IM
>12 years old: 500mcg (0.5 mL) IM
Adult: 500mcg (0.5 mL) IM
References
Thain S, Rubython J. Treatment of anaphylaxis in adults: results of a survey of doctors at Dunedin Hospital, New Zealand. N Z Med J, 2007;120:1252.
Droste J, Narayan N. Hospital doctor’s knowledge of adrenaline (epinephrine) administration in anaphylaxis in adults is deficient. Resuscitation 2010;81:1057–8.
Anaphylaxis guidelines, Royal Children’s Hospital, Melbourne.
