381 - Identification of children with anaphylaxis who may not require ED care: a 30-center retrospective cohort study

Monday, May 1, 2023

9:30 AM – 11:30 AM ET

Poster Number: 381
Publication Number: 381.405

Tim Dribin, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Yin Zhang, Cincinnati Children's Hospital Medical Center, West Chester, OH, United States; Stephanie Boyd, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Kenneth Michelson, Boston Children's Hospital, Boston, MA, United States; Mark I. Neuman, Boston Children's Hospital, Boston, MA, United States; David Brousseau, Medical College of Wisconsin, Milwaukee, WI, United States; Rakesh D.. Mistry, Children's Hospital Colorado, Aurora, CO, United States; Nanhua Zhang, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Hugh A. Sampson, Icahn School of Medicine at Mount Sinai, Greenwich, CT, United States; Paul L. Aronson, Yale School of Medicine, New Haven, CT, United States; Kelly R. Bergmann, Children’s Minnesota, Minneapolis, MN, United States; Brittany Boswell, Stanford University School of Medicine, Palo Alto, CA, United States; sri S. chinta, Medical College of Wisconsin/children's hospital of wisconsi, milwaukee, WI, United States; Wee Chua, Havard University, Needham, MA, United States; Ari Cohen, Massachusetts General Hospital, Boston, MA, United States; Joanna Cohen, Johns Hopkins Children's Center, Washington, DC, United States; Alicia Daggett, Children's Mercy Hospitals and Clinics and Vibrant Health, Kansas City, KS, United States; Justin Davis, University of Mississippi School of Medicine, 5 West Eden Elm Circle, TX, United States; Stephen Freedman, University of Calgary, Calgary, AB, Canada; julia freeman, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, CO, United States; Kajal Khanna, Stanford University School of Medicine, Palo Alto, CA, United States; Curtis L. Knoles, Children’s Hospital at OU Health, Jones, OK, United States; Karen Y. Kwan, Children’s Hospital Los Angeles Division of Emergency and Transport and Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, United States; Chari Larsen, University of Utah School of Medicine, Salt Lake City, UT, United States; Juhee Lee, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Tamar R. Lubell, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Ashley Metcalf, UCSD, San Diego, CA, United States; Matthew M. Moake, Medical University of South Carolina, Charleston, SC, United States; Jo-Ann O. Nesiama, UT Southwestern/ Children’s Medical Center, Dallas, Dallas, TX, United States; Thuy L.. Ngo, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Christian D. Pulcini, Robert Larner, M.D., College of Medicine at the University of Vermont, Burlington, VT, United States; Christopher J.. Russo, NemoursAlfred I. duPont Hospital for Children, Philadelphia, PA, United States; Nidhi Singh, Baylor College of Medicine, HOUSTON, TX, United States; Jonathan Strutt, The University of Minnesota, Minneapolis, MN, United States; Vandana Thapar, University of Texas, Houston Health Center, Houston, TX, United States; Craig Vander Wyst, Children's Hospital Colorado, Denver, CO, United States; Patrick S. Walsh, Medical College of Wisconsin, Milwaukee, WI, United States; Yonatan Wolnerman, Albert Einstein College of Medicine, Bala Cynwyd, PA, United States; DAVID SCHNADOWER, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States

Presenting Author(s)

Tim Dribin, MD (he/him/his)

Assistant Professor Emergency Medicine
Cincinnati Children's Hospital Medical Center
Cincinnati, Ohio, United States

Background:

National anaphylaxis guidelines recommend all patients treated with epinephrine in the community be transported to an emergency department (ED). However, this one size fits all practice recommendation has been questioned because reactions necessitating > 1 dose of epinephrine are rare.

Objective:

To identify children with anaphylaxis treated with epinephrine in the pre-ED setting for whom no further epinephrine was administered in the ED, potentially indicating that ED evaluation may not be necessary.

Design/Methods:

We conducted a retrospective cohort study across 30 North American EDs belonging to the Pediatric Emergency Medicine Collaborative Research Committee. Patients 6 months to < 18 years of age were eligible if they presented to a participating ED with anaphylaxis and received a single dose of epinephrine prior to ED arrival between October 2015 - December 2019. The primary outcome was receipt of epinephrine after ED arrival. Candidate predictors were limited to variables preceding ED arrival. We derived the rule in 70% of the cohort using LASSO regression and validated the rule in the remaining 30%. We sought to maximize the sensitivity and negative predictive value to minimize misclassifying patients as low risk who in fact received epinephrine after ED arrival.

Results:

2,318 eligible patients were included in the analyses. The median patient age was 8.3 years (IQR 3.8, 13.4), foods were the most common trigger (77.1%), and 365 (15.7%) patients received epinephrine after ED arrival (see Table). The rule included the following predictors of epinephrine administration after ED arrival: age > 10 years (OR 1.1 [1.0, 1.5]), history of anaphylaxis to current allergen (OR 1.2 [1.0, 1.5]), history of asthma (OR 1.3 [1.0, 1.6]), persistent symptoms after pre-ED epinephrine (OR 4.5 [2.8, 5.8]), pre-ED respiratory or cardiovascular involvement (OR, 1.1 [1.0, 3.5]), and no pre-ED antihistamine use (OR 1.0 [1.0, 1.4]). The prediction rule (absence of all risk factors) had a sensitivity of 97.3% and a negative predictive value of 91.8% for identifying patients that did not receive epinephrine after ED arrival.

Conclusion(s):

We derived and validated a clinical prediction rule to identify children with anaphylaxis who may not require ED care. Prospective refinement and validation of the rule and application in clinical care may reduce unnecessary ED utilization for anaphylaxis that can be safely managed in the community.