Refractory anaphylaxis A = Airway
Partial upper airway obstruction/stridor:
Nebulised adrenaline (5mL of 1mg/mL)
No improvement in respiratory or cardiovascular symptoms Total upper airway obstruction:
despite 2 appropriate doses of intramuscular adrenaline Expert help needed, follow difficult airway algorithm
B = Breathing
Establish dedicated Seek expert1 help early
Oxygenation is more important than intubation
peripheral IV or IO access Critical care support is essential
If apnoeic:
• Bag mask ventilation
• Consider tracheal intubation
Give rapid IV fluid bolus Start adrenaline infusion Severe/persistent bronchospasm:
e.g. 0.9% sodium chloride
& Adrenaline is essential for treating
• Nebulised salbutamol and ipratropium with oxygen
• Consider IV bolus and/or infusion of salbutamol or
all aspects of anaphylaxis
aminophylline
• Inhalational anaesthesia
Give IM* adrenaline Follow local protocol
every 5 minutes until adrenaline C = Circulation
infusion has been started OR
Peripheral low-dose IV adrenaline infusion: Give further fluid boluses and titrate to response:
*IV boluses of adrenaline are
• 1 mg (1 mL of 1 mg/mL [1:1000]) adrenaline in Child 10 mL/kg per bolus
not recommended, but may be
100 mL of 0.9% sodium chloride Adult 500–1000 mL per bolus
appropriate in some specialist
• Use glucose-free crystalloid
settings (e.g. peri-operative) while • Prime and connect with an infusion pump via a
dedicated line (e.g. Hartmann’s Solution, Plasma-Lyte®)
an infusion is set up
Large volumes may be required (e.g. 3–5 L in adults)
DO NOT ‘piggy back’ on to another infusion line
Place arterial cannula for continuous BP monitoring
DO NOT infuse on the same side as a BP cuff as this will
interfere with the infusion and risk extravasation Establish central venous access
Give high flow oxygen
Titrate to SpO2 94–98% • In both adults and children, start at 0.5–1.0 mL/kg/hour, IF REFRACTORY TO ADRENALINE INFUSION
and titrate according to clinical response Consider adding a second vasopressor in addition
• Continuous monitoring and observation is mandatory to adrenaline infusion:
• ↑↑ BP is likely to indicate adrenaline overdose • Noradrenaline, vasopressin or metaraminol
Monitor HR, BP, pulse oximetry • In patients on beta-blockers, consider glucagon
and ECG for cardiac arrhythmia Consider extracorporeal life support
Take blood sample
for mast cell tryptase Continue adrenaline infusion
and treat ABC symptoms Cardiac arrest – follow ALS ALGORITHM
• Start chest compressions early
Titrate according to clinical response
• Use IV or IO adrenaline bolus (cardiac arrest protocol)
• Aggressive fluid resuscitation
Intravenous adrenaline for anaphylaxis to be given only by experienced specialists in an appropriate setting.
1 • Consider prolonged resuscitation/extracorporeal CPR
