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Adrenaline in anaphylaxis: overtreatment in theory, undertreatment in reality
  1. Peter Storey,
  2. Penny Fitzharris
  1. Immunology Department, Auckland City Hospital, Auckland, New Zealand
  1. Correspondence to Dr Penny Fitzharris, Immunology Department, Auckland City Hospital, Park Road, Auckland 1111, New Zealand; pennyf{at}

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‘Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its management’.1 Few health professionals would disagree with this opening sentence of new guidelines from the European Academy of Allergy and Clinical Immunology (EAACI), which aim to provide evidence-based recommendations for recognition, risk assessment, and management of patients who have experienced, are experiencing or are at risk of experiencing anaphylaxis. This care requires correct recognition of anaphylaxis, appropriate acute management and optimal long-term care: all important but distinct skills.

Guidelines clarify what treatment should be given to whom and when. It would be hoped that, over time with codification of best practice, doctors’ abilities to accurately recognise and appropriately treat anaphylaxis would improve. However, Plumb and colleagues found, using brief written case scenarios, that junior doctors today seem to be no better at correctly identifying the clinical need for, and correct dose and route for administration of, adrenaline (epinephrine) than their predecessors a decade earlier.2

All doctors in this recent study recognised adrenaline as the appropriate treatment for a case scenario that clearly described anaphylaxis. However, many (21–82%) also selected adrenaline as treatment for scenarios describing situations in which adrenaline would not be appropriate—for example, inhalation of peanut or acute urticaria with no other system involvement. Little seems to have changed over time. A decade earlier, all junior doctors at the same hospital tested using the same scenarios selected adrenaline as treatment of choice for anaphylaxis, but some (10–56%) also indicated that they would use adrenaline for inappropriate scenarios.

Similar results have been found elsewhere in the world. In our recent unpublished study from Auckland, all 22 postgraduate year 1 doctors tested using similar scenarios selected adrenaline to treat anaphylaxis, but 27–91% would also have used adrenaline inappropriately.

A questionnaire study of doctors and nurses …

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