The concept of refractory anaphylaxis points to a scenario where the standard therapeutic approach yields inadequate results. This condition may stem directly from the anaphylactic episode itself or be exacerbated by pre-existing medical or surgical conditions, as well as by the effects of anesthesia. In instances where a substantial response remains elusive after 10 minutes, despite appropriate administration of epinephrine and fluids, a re-evaluation and escalation of management tactics such as the ones below are warranted:
Suggestions propose doubling the initial epinephrine bolus dose followed by the initiation of an epinephrine infusion after a TOTAL of three bolus doses have been administered. In the face of persistent, life-threatening hypotension, recommendations are to verify the administration of a sufficient volume of intravenous fluids and give intravenous glucagon (for patients on beta-adrenergic receptor blockers) at a dose of 1–2 mg. Alternative vasopressors such as vasopressin, norepinephrine, metaraminol, or phenylephrine should be contemplated in cases where hypotension persists. The consideration of extracorporeal life support is also advised, provided the requisite expertise and equipment are accessible.
For ongoing, life-threatening bronchospasm, the inclusion of inhaled bronchodilators, and possibly intravenous bronchodilators, is recommended. It is also advised that sugammadex should not be considered as an immediate tool in the resuscitation efforts for suspected anaphylaxis.
