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Anaphylaxis in PICU

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This guideline is for the management of anaphylaxis in the intensive care setting only.


Skin flushing, wheals, rash, oedema of eyelids and lips
CVS  vasodilation, hypotension, tachycardia, cardiac arrest
Respiratory bronchospasm, oedema of upper airway mucosa
Haematologic eosinophilia



  • Call for assistance
  • Remove trigger agent
  • Ensure clear airway adequate ventilation
  • External cardiac massage if necessary
  • Fluid bolus 20 ml/kg, repeated as required
  • Adrenaline 1/1000 0.01 ml/kg IM
    Min Dose 0.1ml, Max Dose 0.5ml. Repeat Q5-10 mins if no improvement

    If loss of cardiac output:
  • Adrenaline 10 mcg/kg (0.1 ml/kg of 1/1000) IV, repeat as required


  • Hydrocortisone 4mg/kg initially then 2mg/kg Q6H
  • Antihistamines: Chlorpheniramine 0.25 mg/kg / 6 hourly
                              Ranitidine 1 mg/kg 6 hourly
  • Inhaled adrenaline to treat upper airway obstruction (Stridor) - Nebulised Adrenaline 1:1000 0.5ml/kg, max 5mls
  • Inhaled bronchodilators to treat bronchospasm (Wheeze) - Salbutamol Neb 5mg
  • Intravenous Salbutamol/Aminophylline bronchospasm resistant to inhaled therapy (continue IM or IV adrenaline)
  • Adrenaline infusion if repeated IM adrenaline doses required
  • Noradrenaline or vasopressin infusion may be required in severe cases


  • Blood gas analysis
  • Clotting screen
  • Serum Tryptase concentration - immediate and another at 6 h
  • Retain suspect drugs and fluids


  • Arrange for skin and radioimmunoassay testing (Dept Anaesthesia)
  • Patient education
  • Medic Alert

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Document Control

  • Date last published: 06 December 2015
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Editor: John Beca
  • Review frequency: 2 years