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. 2021 Jul;148(1):173-181.
doi: 10.1016/j.jaci.2021.01.003. Epub 2021 Jan 19.

Severity grading system for acute allergic reactions: A multidisciplinary Delphi study

Timothy E Dribin  1 , David Schnadower  2 , Jonathan M Spergel  3 , Ronna L Campbell  4 , Marcus Shaker  5 , Mark I Neuman  6 , Kenneth A Michelson  6 , Peter S Capucilli  7 , Carlos A Camargo Jr  8 , David C Brousseau  9 , Susan A Rudders  10 , Amal H Assa'ad  11 , Kimberly A Risma  11 , Mariana Castells  12 , Lynda C Schneider  10 , Julie Wang  13 , Juhee Lee  3 , Rakesh D Mistry  14 , David Vyles  9 , Michael Pistiner  15 , John K Witry  16 , Yin Zhang  17 , Hugh A Sampson  13
Affiliations

Severity grading system for acute allergic reactions: A multidisciplinary Delphi study

Timothy E Dribin et al. J Allergy Clin Immunol. 2021 Jul.

Abstract

Background: There is no widely adopted severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions, thus limiting the ability to optimize and standardize management practices and advance research.

Objective: The aim of this study was to develop a severity grading system for acute allergic reactions for use in clinical care and research.

Methods: From May to September 2020, we convened a 21-member multidisciplinary panel of allergy and emergency care experts; 9 members formed a writing group to critically appraise and assess the strengths and limitations of prior severity grading systems and develop the structure and content for an optimal severity grading system. The entire study panel then revised the grading system and sought consensus by utilizing Delphi methodology.

Results: The writing group recommended that an optimal grading system encompass the severity of acute allergic reactions on a continuum from mild allergic reactions to anaphylactic shock. Additionally, the severity grading system must be able to discriminate between clinically important differences in reaction severity to be relevant in research while also being intuitive and straightforward to apply in clinical care. Consensus was reached for all elements of the proposed severity grading system.

Conclusion: We developed a consensus severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions. Successful international validation, refinement, dissemination, and application of the grading system will improve communication among providers and patients about the severity of allergic reactions and will help advance future research.

Keywords: Allergic reactions; Delphi; anaphylaxis; emergency department; severity.

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Figures

FIG 1.
FIG 1.
Severity grading system for acute allergic reactions. *The severity grading system is designed for use across the spectrum of acute allergic reactions, as depicted by the vertical arrow (mild to life-threatening reactions), regardless of whether they fulfill the NIAID/FAAN criteria for anaphylaxis. **For patients with multiple symptoms, reaction severity is based on the most severe symptom; symptoms that constitute more severe grades always supersede symptoms from less severe grades. The grading system can be used to assign reaction severity at any time during the course of reactions; reactions may progress rapidly (within minutes) from one severity grade to another. The grading system does not dictate management decisions; reactions of any severity grade may require treatment with epinephrine. †Patients with severe cardiovascular and/or neurologic involvement may have urinary or stool incontinence. However, the significance of incontinence as an isolated symptom is unclear, and it is therefore not included as a symptom in the subgrading system. ††Abdominal pain may also result from uterine cramping.
FIG 2.
FIG 2.
Severity grading system for acute allergic reactions (pocket guide). *The severity grading system is designed for use across the spectrum of acute allergic reactions regardless of whether they fulfill the NIAID/FAAN criteria for anaphylaxis. **For patients with multiple symptoms, reaction severity is based on the most severe symptom; symptoms that constitute more severe grades always supersede symptoms from less severe grades. The grading system can be used to assign reaction severity at any time during the course of reactions; reactions may progress rapidly (within minutes) from one severity grade to another. The grading system does not dictate management decisions; reactions of any severity grade may require treatment with epinephrine.
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