Finger Injection with High-Dose (1:1,000) Epinephrine: Does it Cause Finger Necrosis and Should it be Treated?

Objectives Accidental finger injections with high-dose (1:1,000) epinephrine is a new and increasing phenomenon. The purpose of this study is to document the incidence of finger necrosis and the treatment for this type of injury. The necessity or type of treatment required for this type of injury has not been established. Methods The literature was reviewed from 1900 to 2005 by hand and by Internet to document all cases of high-dose (1:1,000) finger epinephrine injection. In addition, the authors added five additional cases. Results There are a total of 59 reported cases of finger injections with high-dose epinephrine, of which, 32 cases were untreated. There were no instances of necrosis or skin loss, but neuropraxia lasting as long as 10 weeks and reperfusion pain were carefully documented. Treatment was not uniform for those who received it, but phentolamine was the most commonly used agent. Conclusions There is not one case of finger necrosis in all of the 59 reported cases of finger injections with 1:1,000 epinephrine in the world literature. The necessity or type of treatment of high-dose epinephrine injection injuries remains conjecture, but phentolamine is the most commonly used agent in the reported cases, and the rationale and evidence for its use are discussed     

An Internet-based survey of anaphylactic reactions to foods

BACKGROUND: A favorable outcome of anaphylaxis depends on the rapidity of adequate initial management and epinephrine injection. However, few data on the management of anaphylactic reactions are available. The aim of this study was to investigate the management and awareness of anaphylaxis to foods by mean of an Internet-based survey. METHODS: Visitors to a website with information on food allergy were invited to join the survey. Items in the survey included the management of anaphylactic reactions, investigations done by the diagnosing physician, and information given to the responder in anticipation of a new anaphylactic reaction. RESULTS: Almost all of the 264 responders were from North America, Europe, Australia, or New Zealand (263/264). The most recent reaction was treated by epinephrine injection in 68.7% (180/262) of cases, or by antihistamines in 14.1% (37/262). Epinephrine was the first treatment for the most severe reaction in only 43.9% (101/230), while antihistamines were given first in 43.5% (100/230). One-third (62/210 = 29.5%) of the responders diagnosed by a physician received neither a diagnostic blood test nor a skin test. Responders diagnosed by an allergist were more often investigated (91/105 = 86.7%) than those diagnosed by a pediatrician or an internist (29/44 = 65.9%), a general practitioner (22/45 = 48.9%), or another physician (6/16 = 37.5%) (P < 0.001). Most responders had received instructions on how to deal with a new episode of anaphylaxis (244/263 = 92.8%). Responders instructed by an allergist were most frequently satisfied with the instructions (115/131 = 87.8%). CONCLUSION: A large number of responders did not receive epinephrine for treatment of their most severe, or most recent anaphylactic reaction, and did not undergo allergy tests. The conventional management of anaphylaxis might still be improved.     

肾上腺素及地塞米松对白内障患者晶状体上皮细胞增殖的影响

为了观察肾上腺素及地塞米松对白内障患者晶状体上皮细胞 (lensepithelialcell,LEC)增殖的影响并探讨其机制 ,在行白内障超声乳化术中 ,取出中央 5～ 7mm的晶状体前囊 ,将其均分成 3等份 ,用于对照组及两实验组 ,分别培养于 10 -6mol/L的肾上腺素及地塞米松 4 8h,免疫组织化学染色后 ,采用医用多功能图像分析系统测定增殖细胞核抗原 (proliferatingcellnuclearantigen ,PCNA)阳性面积率。结果显示 ,10 -6mol/L的肾上腺素及地塞米松对LEC的增殖有明显的抑制作用 ,PCNA的阳性面积率分别为 (2 6 14± 0 92 2 ) %和(3 338± 0 838) % ,与对照组比较 ,差异有显著性意义 (P <0 0 1)。研究表明 ,肾上腺素及地塞米松对白内障患者LEC有明显的抑制作用 ,从而可用于白内障术后防治后囊膜混浊的发生 ,为临床筛选防治后发性白内障的药物提供了科学依据。     

肾上腺素诱导人视网膜色素上皮细胞凋亡的实验研究

目的　观察肾上腺素对体外培养人视网膜色素上皮 (RPE)细胞凋亡的影响 ,探讨细胞凋亡与中心性浆液性脉络膜视网膜病变的关系。方法　通过流式细胞技术 (FCM )、光镜、TUNEL细胞凋亡原位末端标记法检测肾上腺素和 β 受体阻滞剂普萘洛尔对体外培养的人RPE细胞凋亡的作用。 结果　人RPE细胞对低浓度的肾上腺素有一定耐受作用 ,10 pg/ml～ 10 4pg/ml肾上腺素组无明显凋亡的发生 ;10 5pg/ml～ 10 8pg/ml肾上腺素诱导RPE细胞 72h可以检测到凋亡峰 ,与对照组比较有显著性差异 (P <0 0 1) ;加入 10 3 pg/ml普萘洛尔可以提高RPE细胞对肾上腺素毒性作用的耐受 ,未检见RPE细胞凋亡的发生。TUNEL法光镜下观察到细胞核被蓝色染料标记的凋亡细胞。结论　肾上腺素可以诱导培养的人RPE细胞凋亡 ,这可能是中心性浆液性脉络膜视网膜病变早期病理改变的机制之一。     

Functional analysis of the marginating pool of human polymorphonuclear leukocytes

The intravascular pool of human polymorphonuclear leukocytes (PMN) is composed of one compartment which is circulating and another that is marginated to the vascular endothelium. Administration of B-adrenergic agonists leads to a rapid demargination with an increase in the circulating PMN pool. The marginating PMN has previously been stated to represent an older PMN based on a higher cytochemical alkaline phosphatase activity. With the understanding that circulating PMN are heterogeneous with respect to function and size we undertook the present study to evaluate the contribution of the marginating PMN to functional and volume-dependent heterogeneity. We found that PMN isolated 7 min after epinephrine administration, presumably enriched by marginating PMN, were not different in volume, biochemically measured alkaline phosphatase activity, stimulated superoxide anion release, degranulation, or phagocytosis. These data suggest that the circulating and marginating pools of PMN are interchangeable and that the marginating PMN are not enriched by a particular subpopulation of PMN.     

Relatively light general anesthesia is more effective than fluid expansion in reducing the severity of epinephrine-induced hypotension during functional endoscopic sinus surgery

Background Epinephrine infiltration of the nasal mucosa causes hypotension during functional endoscopic sinus surgery (FESS) under general anesthesia. A prospective randomized-controlled study was designed to determine whether relatively light general anesthesia is superior to fluid expansion in reducing epinephrine-induced hypotension during FESS. Methods Ninety patients undergoing elective FESS under general anesthesia were randomly assigned to three groups with 30 patients in each. Each patient received local infiltration with adrenaline-containing (5 &micro;g/ml) lidocaine (1%, 4 ml) under different conditions. For Group I, anesthesia was maintained with propofol 2 &micro;g/ml and rimifentanil 2 ng/ml by TCI. Group II (control group) and Group Ⅲ received propofol 4 &micro;g/ml and rimifentanil 4 ng/ml, respectively. In Groups I and II, fluid expansion was performed with hetastarch 5 ml/kg within 20 minutes; hetastarch 10 ml/kg was used in Group Ⅲ. Mean arterial pressure (MAP) and heart rate (HR) were recorded at 30-second-intervals for 5 minutes after the beginning of local infiltration. Simultaneously, the lowest and the highest MAP were recorded to calculate the mean maximum increase or decrease percent in MAP for all patients in each group. Data analysis was performed by χ(2) test, one-way analysis of variance, or one-way analysis of covariance.Results Hemodynamic changes, particularly a decrease in MAP accompanied by an increase in HR at 1.5 minutes (P&lt;0.05), were observed in all groups. The mean maximum decrease in MAP below baseline was 14% in Group I, 24% in Group Ⅲ and 26% in Group II. There were statistically significant differences between Group I and Groups II and Ⅲ (P&lt;0.05). The mean maximum increase in MAP above baseline was 9% in Group I, 6% in Group Ⅲ and 2% in Group II. Conclusion Relatively light general anesthesia can reduce the severity of epinephrine-induced hypotension more effectively than fluid expansion during FESS under general anesthesia.     

Barriers to the Administration of Epinephrine in Schools

BACKGROUND

Anaphylaxis is a serious and growing concern in the school setting as the prevalence of food allergies and food‐induced severe allergic reactions continues to increase.

METHODS

A cross‐sectional, web‐based survey was conducted regarding anaphylactic events that occurred during the 2014‐2015 school year. Eligible schools were enrolled in the EPIPEN4SCHOOLS^® program (Mylan Specialty L.P., Canonsburg, PA), which provides free epinephrine auto‐injectors to qualifying US schools. Participating schools completed a 29‐item survey on anaphylactic event occurrence and treatment, epinephrine stock, school policies regarding anaphylaxis, school staff training, and school nursing coverage.

RESULTS

Responses were provided by 12,275 schools. Epinephrine was administered on school property for 63.7% of reported anaphylactic events (1272/1998). In 38.5% (235/610) of events for which epinephrine was not used, antihistamines were cited as the reason. Only 59.4% of schools cited epinephrine as their standard first‐line therapy for anaphylaxis. School nurses were most likely to be trained in anaphylaxis recognition and permitted to administer epinephrine; however, just 53.6% of schools had a full‐time nurse on staff.

CONCLUSIONS

Process‐related barriers to the appropriate use of epinephrine go beyond access to medication. Widespread staff training and review of school policies are needed to ensure that anaphylaxis is appropriately managed in schools.

     

Effectiveness of Prehospital Epinephrine Administration in Improving Long-term Outcomes of Witnessed Out-of-hospital Cardiac Arrest Patients with Initial Non-shockable Rhythms

Objective: We evaluated the association between prehospital epinephrine administration by emergency medical services (EMS) and the long-term outcomes of out-of-hospital cardiac arrest (OHCA) with initial pulseless electrical activity (PEA) or asystole. Methods: We conducted a controlled, propensity-matched, retrospective cohort study by using Japan's nationwide OHCA registry database. We studied 110,239 bystander-witnessed OHCA patients aged 15–94 years with initial non-shockable rhythms registered between January 2008 and December 2012. We created 1–1 matched pairs of patients with or without epinephrine by using sequential risk set matching based on time-dependent propensity scores to balance the patients' severity and characteristics. We compared overall and neurologically intact survival 1 month after OHCA between cases and controls using conditional logistic regression models by category of the initial rhythm. Results: Propensity matching created 7,431 pairs in patients with PEA and 8,906 pairs in those with asystole. Epinephrine administration was associated with higher overall survival (4.49% vs. 2.96%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.30–1.85) but not with neurologically intact survival (0.98% vs. 0.78%; OR, 1.26; 95% CI, 0.89–1.78) in patients with PEA, and with higher overall survival (2.38% vs. 1.04%; OR, 2.34; 95% CI, 1.82–3.00) and neurologically intact survival (0.48% vs. 0.22%; OR, 2.28; 95% CI, 1.31–3.96) in those with asystole. Conclusions: Prehospital epinephrine administration by EMS is favorably associated with long-term neurological outcomes in patients with initial asystole and with long-term survival outcomes in those with PEA.