Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : December | Volume : 4 | Issue : 6 | Page : 3474 - 3479

Treatment Of Anaphylaxis In Adults: A Questionnaire Survey At S. Nijalingappa Medical College Hospital, Bagalkot, India

PRABHU S B* AND YASMEEN M**

*Lecturer at Dept of Pharmacology, S.Nijalingappa Medical College, **Bagalkot; Prof & HOD, Dept of Pharmacology S.Nijalingappa Medical College, Bagalkot

Correspondence Address :
Dr. Prabhu S Bhixavatimath,
Lecturer Dept of Pharmacology,
S.Nijalingappa Medical College, Bagalkot,
Karnataka, INDIA.
E-mail: drprabhusb@gmail.com

Abstract

Objective: To identify as to which medications medical students, interns and casualty medical officers are likely to prescribe when treating an adult patient with anaphylaxis, and to ascertain the dose and route of administration of adrenaline that they would use. Design: A questionnaire study survey.
Setting: S. Nijalingappa Medical College (SNMC) and H.S.K. Hospital, Bagalkot (Bagalkot District) and public health centers (PHCs) of the Bagalkot district, Karnataka.
Methods: The medical students, interns and casualty medical officers of the S.N.M.C and H.S.K. Hospitals and doctors of various grades, working at the public health centers of the Bagalkot district, were asked to anonymously complete a questionnaire detailing a hypothetical case of anaphylaxis. The data were collected from 52 second year medical students, 35 interns and 25 casualty medical officers.
Main outcome measure: To determine the percentage of the use of adrenaline for the treatment of anaphylaxis in the correct dose, strength and route.
Results: 90% of the participants said that they would give adrenaline as a first-line treatment to a patient with anaphylaxis, but only 38% knew the correct dose and route of administration. 52% of the doctors who were surveyed stated that they would give adrenaline by the intravenous (IV) route as the first-line treatment. 67.85% and 20.53% of the participants preferred to use corticosteroids and antihistamines respectively. 3.57% said that they would give antibiotics as second line drugs.
Conclusion: Most of the doctors who were surveyed were not clear about the current anaphylaxis treatment guidelines. In particular, they were unsure of the recommended dose and route of the administration of adrenaline. This confusion applied to all medical students, interns and medical officers. To ensure that the first-line treatment of anaphylaxis is safe, we recommend that intramuscular (IM) adrenaline should be used in the majority of situations like anaphylaxis. We recommend that all doctors should receive regular education concerning the treatment of anaphylaxis.

Keywords

Anaphylaxis, Adrenaline

Introduction
Anaphylaxis is an acute, potentially life-threatening type 1 hypersensitive reaction event, requiring immediate recognition and treatment and it is caused by the release of mediators from mast cells and basophils, following binding with IgE. The term anaphylactoid reaction refers to a non IgE mediated mast cell or basophil activation. The major life-threatening components of anaphylaxis are hypotension, bronchospasm and upper airway angiooedema. The most common of these is cardiovascular collapse. (1), (2), (3) Anaphylaxis can occur unexpectedly (with a wide variety of causes) in any age group, and all doctors should be aware of the immediate treatment. The most common triggering factors are food substances like peanuts, milk and shellfish, drugs like penicillins and cephalosporins and radio contrast media or idiopathic causes. Anaphylaxis is a medical emergency which may require resuscitation measures such as airway management, supplemental oxygen, large volumes of intravenous fluids, and close monitoring. (4) The administration of epinephrine is the treatment of choice, with antihistamines and steroids often used as adjuncts. Epinephrine (adrenaline) is the primary treatment for anaphylaxis with no absolute contraindication to its use. (4) Whilst adrenaline is life-saving, it is also potentially dangerous. It increases heart rate, myocardial irritability, and inotropy, predisposing the myocardium to potentially serious arrhythmias and ischaemia. (1)
Since junior doctors also can be called upon to treat this emergency condition, we planned to conduct this study in interns working at the S.Nijalingappa Medical College Hospital, Bagalkot and also the casualty medical officers (CMO) working at public health centres in the Bagalkot district, who were the first medical responders. We also included the medical students who were being taught on this subject during the second year of the medical curriculum. The aim of this study was to identify the medications that the medical students, interns and casualty medical officers were likely to prescribe when treating an adult patient with anaphylaxis, and to ascertain the dose and route of the administration of adrenaline that they would use. The use of antihistamines and corticosteroids were also studied.

Material and Methods

A total of 112 participants were enrolled in this study, who were randomly selected, which included second year medical students (n=52), interns (n=35) and the CMOs of S.N.M.C and different PHCs of the Bagalkot district.
They were asked to answer a questionnaire which was distributed to them, which contained details of two hypothetical adult cases of anaphylaxis within a specified time, under supervision.
The questionnaires which were used in a previous study (3),(6)&(7) were modified and used in this study. There was no pressure or mandatory rules for the subjects to participate in the study and all were informed well in advance about their participation in the study. The identity of the subjects who participated was kept confidential, but however, all were informed well in advance regarding their grade and speciality will going to state for study survey purpose.

Results

Totally, 112 questionnaires were completed by 52 second year medical students, 35 interns of S. Nijalingappa Medical college Hospital and 25 casualty medical officers of S.N.M.C. and various PHCs of the Bagalkot district, in Karnataka state, India.
When questioned as to which first line treatment should be given to a patient with anaphylaxis (Q1), 101 (90.17%) stated that they would give adrenaline. Out of these 101 participants, 43 (38.39%) stated that they would IM adrenaline and 58 (51.78%) participants opted for IV adrenaline. But, 11 (9.82%) participants stated that they would give other drugs ie hydrocortisone and salbutamol nebulization would be used as first line treatments in anaphylaxis. The results which are related to this are tabulated in (Table/Fig 1). Out of the 43 (38.39%) participants who opted for IM adrenaline as the correct first line treatment 17 (32.69%) included medical students and 23 (65.71%) and 3 (12%) were CMOs. The percentage of participants in each group, opting for different drugs as first line treatments for anaphylaxis is given in Table 1. But, 2% of the total participants selected salbutamol nebulizer, 8.03% chose IV hydrocortisone and 52% of the total participants preferred IV adrenaline as the first line treatment in anaphylaxis.
When asked about the route of adrenaline administration (Q2) and the concentration dilution of adrenaline (Q) which would be preferred in the anaphylaxis condition, only 42 (38%) of the total participants answered the correct dose (0.5mg) and concentration of adrenaline (1:1000) and only 52 (46%) and 42 (38%) of the total participants stated the correct dilution concentration of adrenaline when they were asked separately about the concentration of adrenaline and the route of administration which would be used in anaphylaxis respectively. Though adrenaline has the least oral bioavailability (8), 2 medical students stated that they preferred the oral route of administration. However, 11 (9.82%) of the total participants who answered the questions, did not know about the concentration of adrenaline, which included 4 (7.69%) participants from among the medical students, 6 (17.14%) from among the interns and 1 (4%) from among the CMOs. More than 16-30 participants stated that lower concentrations (1:100000-200000) of adrenaline should be used. Regarding the route of administration, 9 (8.03%) of the total participants mentioned that they preferred the S.C route which would be contraindicated in that case, and 3(12%) of the total CMOs stated that that they preferred the highest concentration of adrenaline, which itself could be a very dangerous.The results of Q2 and Q3, along with the percentages of the participants in each group opting for the route and concentration of adrenaline which they would use in anaphylaxis, have been given in (Table/Fig 2) and (Table/Fig 3). Regarding the timing of the second dose of adrenaline, in cases where the anaphylaxis patients had not shown improvement (Q4), surprisingly 15 (13.39%) of the total participants which included 11 medical students, 3 interns and 1 CMO, stated that they did not know, as their answer (when to be repeat the second dose of adrenaline), and 17(15.17%) candidates (8 medical students, 2 interns and 7 CMO) of the total participants mentioned that there was no need of a second dose of adrenaline.However, 56(50%) participants consisting of of 24 medical students, 22 interns 10 CMO, stated the appropriate time, ie; after 5 min, the second dose of adrenaline could be repeated if the patient had not shown improvement after the first dose. The preferences which were opted for the time to consider a second dose of adrenaline in anaphylaxis by different individual groups along with their percentages, is given in (Table/Fig 4). When asked about the second line of drugs in anaphylaxis (Q5), 76(67.85%) participants and 23 (20.53%) participants said that they preferred to use corticosteroids and H1 antagonists respectively, and 5(4.46%) of the total participants opted for H2 antagonists (ranitidine),but 4 participants selected antibiotics as the second line of drugs in that case. The detailed responses (In % also) given by all participants with respect to question 5 has been given in (Table/Fig 5). When questioned about the guidelines/criteria regarding the management of anaphylaxis (Q6), most of the participants were found to be unaware about the existing guidelines for the management of anaphylaxis.

Discussion

The main purpose of this study was to assess the mode of medications that the doctors and medical students would use in the situation of handling an adult hypothetical anaphylaxis case and to know the route, dose concentration, second dose of adrenaline and second line of drugs that they would use in that situation. A previous study on hospital doctors showed that only 5% were able to state the correct dose and the route of administration of adrenaline to be used in anaphylaxis (5) and there existed confusion in the treatment of this emergency condition. (5)-(7) It is essential that doctors working in the emergency department should be aware of the correct drug, the route of administration and the dose of adrenaline.

We assumed that the basic management steps prior to drug administration would have over (completed) ie; stoppage of administration of offending drug causing the reaction, administration of high flow humidified oxygen inhalation, place the patient in supine position, and call for help etc. When faced with a hypothetical adult case of anaphylaxis, 101 (90.17%) participants in this study stated that they would give adrenaline as their first line of treatment. The other 8.03% said that they would give IV hydrocortisone and 2% said that would give salbutamol nebulization. Though these are useful adjutants in the management of anaphylaxis, adrenaline is the life saving drug and it is considered as the pharmacological antagonist of histamine (which is the main chemical mediator in an anaphylactic reaction), as it reverses the pathophysiological processes which are involved in anaphylaxis by acting on all adrenergic receptors (α1 β1- β2 α2). (9) This study has shown that a considerable amount of confusion existed in the matter of giving adrenaline in its correct dose route of administration in the treatment of anaphylaxis. The confusion had affected all grades of doctors and even the medical students who were studying as a part of the examination in that academic year. In this study, 58(51.78%) participants opted for giving adrenaline by the IV route, 9(8.03%) participants chose the S.C route, 2 (1.78%) medical students opted for the oral route and 1 medical student stated that he/she did not know about which route to use for adrenaline administration and so on.
The bioavailability of adrenaline is unpredictable after the oral and the S.C routes in case of anaphylaxis, as it undergoes the rapid first pass effect through the oral route, and when given through the S.C route, there will be a decreased perfusion at the periphery which leads to the slow or limited absorption of the drug and hence, these two routes are contraindicated in this case.(10) Adrenaline by the IM route is preferred in anaphylaxis and it should be injected without delay in the anterolateral aspect of the thigh, as it leads to a more predictable and rapid absorption of adrenaline, besides avoiding the potential lethal effect of the large bolus of adrenaline by the IV route.(11),(12)
However, bolus IV adrenaline is reserved for life threatening shock, cardiac arrest or for profoundly hypotensive cases who have failed to respond to multiple injections of adrenaline and IV fluid replacement. IV adrenaline should be given by experienced physicians with constant cardiac monitoring (1),(13), which is possible only in the ICCU settings of tertiary care centres. This study has focussed on the fact that many doctors (medical students, interns and casualty medical officers) are unaware regarding the correct dose and the concentration of adrenaline to be used in the treatment of anaphylaxis. In response to question 3, only 52(46.42%) of the total participants (18 medical students, 22 interns and 12 CMOs) stated the correct dose. Surprisingly, 11(9.82%) participants answered that they did not know the correct dose of adrenaline, though they knew that adrenaline had to be given as the first line drug in anaphylaxis treatment.
Alarmingly, 58 participants (52%) stated that they would give an IV dose of adrenaline which could be used only in the emergency management of cardiac arrest. Given that so many participants proposed to give a potentially dangerous dose of IV adrenaline, this finding highlights that there is an intense need to train (educate) the clinical staff to make use of IM adrenaline in most of the cases of anaphylaxis as per the current guidelines. This would ensure that the first line treatment of anaphylaxis was appropriate. 3 participants have opted for the use of a higher concentration (1:100) of adrenaline and 17(15.17%) participants have asserted that the second dose of adrenaline could not be given. However, 56-60(50%-54%) participants from among the total participants stated the correct answer for question 4, that a second dose of adrenaline needed to be administered in severe anaphylaxis. However, the second dose of adrenaline can be repeated every 5-15 min in severe cases of anaphylaxis if the patient had not improved after the first dose of adrenaline(11) All this implies that the clinical staff should be educated (trained) intermittently/repeatedly through continued medical education like programmes.
With respect to the second line of drugs in the management of anaphylaxis (Q5), a majority of the participants opted for IV hydrocortisone and H1 receptor antagonists like diphenhydramine, and H2 receptor blockers like ranitidine. Though these drugs were recommended, there is a little evidence to support their benefit in anaphylaxis. (14) However, the selection of the second line drugs as adjuvants are based on the associated existing cutaneous manifestations like urticaria, angiooedema, pruritis and/or GIT symptoms, etc. Few participants opted for IV fluids, IV antibiotics and salbutamol nebulization as the preferred second line of drugs. This reflects the clinical details described in the problem. However, inhalational beta -2 agonists like salbutamol/formoterol or IV aminophylline infusion can be beneficial if anaphylaxis is associated with bronchospasm, and IV hydrocortisone may reduce the prolonged reactions and relapse.(11) Diuretics, NSAIDs and antibiotics have no role in anaphylaxis treatment. This survey reflects the range of doctors who may be called upon to treat the patients with anaphylaxis and hence, it is necessary that all doctors should know how to treat this medical emergency or otherwise, they have to get trained by attending CME programmes on the management of anaphylaxis.
However, a larger study provides the differences between the grades and specialities for them to be examined in more detail. This type of study may also help to explore the relationship between various guidelines and the proposed adrenaline management.
In addition, more information could be obtained by performing a multricentric study including a survey of general practitioners, nurses and other emergency response personnel.

Conclusion

This study conveys the message that most doctors would prefer the use of adrenaline as a life saving measure when faced with an adult anaphylaxis case. This survey reflects the knowledge of the students and doctors who may be called to treat the patients with anaphylaxis. Since some sort of confusion exists with some doctors with respect to the adrenaline dose concentration and its route of administration, they need to look into the resuscitation guidelines which are put forward by various sources which are found to be almost similar (5), (6)&(7) for the management of anaphylaxis like cases.
According to the local and national guidelines, it is recommended that adrenaline should be given intramuscularly in case of anaphylaxis treatment as a first line drug and IV adrenaline should be kept as a reserve for life threatening cardiac arrest which should be handled by experts under close monitoring.
The life time risk of anaphylaxis is presumed to be 1% -3% per individual with a mortality rate of 1%. (13) Hence, all of our doctors should be able to diagnose anaphylaxis and treat it efficiently. Finally, all doctors need to know where the treatment guidelines can be found quickly.

References

1.
Level 7 Medical Provider Handbook. New Zealand Resuscitation Council Inc; 2001:111–6.
2.
Marshall SE, Immunological factors in medicine, In: Boom NA, Colledge NR, Walker BR, Hunter JAA. Davidson’s principles and practice of medicine. 20th ed, New York: Elsevier Health Sciences 2006; p 465-47
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Adiga S, Nayak V, Bairy KL. Treatment of Anaphylaxis in Adults: A Questionnaire Survey Online J Health Allied Scs. 2008; 7(4):68.
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Simons FE (October 2009). "Anaphylaxis: Recent advances in assessment and treatment". J.Allergy Clin.immunol, 124(4):625-36; quiz637-8.
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Gompels LL, Bethune C, Johnston SL, Gompels MM. Proposed use of adrenaline (epinephrine) in anaphylaxis and related conditions: a study of senior house officers starting accident and emergency posts. Postgrad Med J 2002; 78:416–418.
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Suzy T, Jill R, Treatment of anaphylaxis in adults: results of a survey of doctors at Dunedin Hospital, New Zealand. The New Zealand Medical journal 2007; 120:1252-1258.
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Ricardo J, Gerald JC. Survey of the use of epinephrine (adrenaline) for anaphylaxis by junior hospital doctors. Postgrad Med J 2007; 83:610-611.
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Hardman JG, Limard lE, et al (Edn): Goodman and Gilman’s The Pharmacological Basis of Therapeutics 11th edn: McGraw-Hill, New, 2006.
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Hoffman BB. Adrenoceptor-activating and other sympathomimetic drugs. In Katzung BG, Basic and clinical pharmacology.10th edn, Singapore: McGraw-Hill companies: 2007.p137.
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Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. 2001; 108:871–3.
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Kishiyama JL, Adelman DC. Allergic and immunologic disorders, In: McPhee SJ, Papadakis MA, Tierney LM. Current medical diagnosis and treatment. 47th edition, New York: McGraw-Hill companies. 2008. p691
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Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000; 30:1144–50.
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Oswalt ML, Kemp SF. Anaphylaxis: Office management and prevention. Immunol Allergy Clin N Am 2007; 27:177-91.
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Brown SG. Anaphylaxis: clinical concepts and research priorities. Emerg Med Australia. 2006; 18:155–69.

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