Anaphylaxis — Anaphylaxis Medications — Clinical Pathway: Emergency Department, Inpatient and Outpatient Specialty Care

Anaphylaxis — Anaphylaxis Medications — Clinical Pathway: Emergency Department, Inpatient and Outpatient Specialty Care

Anaphylaxis: Respiratory Medications, Vasopressors and Adjunctive Medications

Respiratory Medications

Albuterol weight-based dosing

Kg Unit Dose (0.5%) MDI puffs Continuous
< 5 1.25 mg (0.25mL) 2 5 mg/hr
5-10 2.5 mg (0.5 mL) 4 7.5 mg/hr (1.5 ml/hr)
10-20 3.75 mg (0.75 mL) 6 11.25 mg/hr (2.25 ml/hr)
> 20 5 mg (1.0 mL) 8 15 mg/hr (3 ml/hr)

Racemic Epi (1% solution)

Kg Unit Dose
< 5 0.25 mL
5-10 0.5 mL

Vasopressor Medications

Medications Dose
Epinephrine 0.1-1 mcg/kg/min
Dopamine 5-20 mcg/kg/min

For Epinephrine - resistant hypotension:

  • Consider Glucagon if child is on beta blockers and first dose of epinephrine is ineffective
    • 20-30 mcg/kg (max 1 mg in children, 5 mg in adults)
    • IV bolus over 5 min
    • Follow with infusion 5-15 mcg/min titrated to clinical effect

Adjunctive Medications

Antihistamines

Antihistamines (H1) relieve the symptoms, hives/itch, but do not relieve severe symptoms.
Addition of antihistamine (H2) may provide more symptomatic relief for pruritis and abdominal symptoms.

Medication Route Dose Max Dose
Diphenhydramine IV/PO 1 mg/kg 50 mg
Cetirizine PO
  • 6-23 months
    2.5 mg/day
     
  • 2-5 years
    2.5-5 mg/day
     
  • > 6 years
    5-10 mg/day
  • 5 mg
  • 5 mg
  • 10 mg
Famotidine IV 0.25 mg/kg 20 mg
PO 0.5 mg/kg 40 mg

Steroids

For children who respond well to epinephrine, the addition of steroids may not be necessary unless used to treat airway or respiratory disease. There is some thought that it may decrease the risk of biphasic reactions; however a 2020 systematic review failed to document a benefit.

Reference:
Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis  

Medication Route Dose Max Dose
Methylprednisolone IV 2 mg/kg 60 mg
Prednisone/Prednisolone PO 2 mg/kg 60 mg
Dexamethasone PO 0.6 mg/kg 8 mg