Preparing for Anaphylaxis from Fluorescein Angiography

3 02 2010

I was interviewed for an article that appeared in the January issue of Retinal Physician magazine. The article was titled, “Putting ‘Management’ Into Risk Management: Proactive policies for keeping patients safe.” My discussion regarding developing a plan for performing fluorescein angiography were rather comprehensive, so Retinal Physician turned it into a sidebar in the article. In my comments I mentioned that the protocol we developed for our office is available here at The Retina Blog. For some reason it seems to have disappeared. If you would like a copy, leave a comment (it will show your email address to me, but no one else can see it) and I’d be happy to send the protocol to you. I only ask that you let me know how useful you find the protocol, and if you have any suggestions for improvements.

Here is my discussion in the January 2010 issue of Retinal Physician:


The biggest risk we need to be prepared for in retina practices is anaphylaxis from fluorescein angiography. A publication this past summer showed the incidence of anaphylaxis is one per 350 fluoresceins.2 Because anaphylaxis can be life threatening, and because it is treatable, we must train our staff to recognize it — and our retina practices must be prepared to deal with it.

Anaphylaxis is a multisystem allergic reaction. The severity of the reaction is difficult to predict at its outset, and the internal medicine literature advocates treating it early with subcutaneous or intramuscular epinephrine (1:1000). Anaphylaxis can involve four major organ systems: respiratory, cardiovascular, gastrointestinal and cutaneous. Involvement of any two of these organ systems meets the definition of anaphylaxis. So if a patient has itching and shortness of breath, the internal medicine literature advocates treating with epinephrine. I think many of us are hesitant to give epinephrine in our practices because of the potential risks in our patients with diabetes and cardiac disease. But it’s certainly worth having epinephrine on hand. It’s also important to have a protocol in place.

In developing protocols for our practice, I consulted with other retina specialists to see what protocols they had in place. At hospital-based practices, the most common protocol was “call the code blue team.” Most private practices I spoke to don’t have written protocols. In developing ours, I sought the advice of my colleagues in internal medicine, emergency medicine and anesthesia. Among these specialties, they advocated a wide range of reasonable approaches. If you have easy access to a 911 team, then your protocol can be minimal — administer diphenhydramine, maybe epinephrine, and monitor blood pressure. If, however, you want to be more complete, because of a slower anticipated response time, your protocol could include administering oxygen or IV fluids, monitoring oxygen saturation and a cardiac tracing, and having available an airway, bag and an automatic external defibrillator.

Our protocol is primarily a checklist that includes several sections: preparation, which includes checking the blood pressure and pulse, reviewing drug allergies, pregnancy, and any history of prior cardiac or respiratory problems. Most of these data are already on the chart, so this portion of the checklist is a sort of a “time out” to review things before injecting the fluorescein.

The second portion of the checklist addresses things that must be available prior to injecting: Personnel —which is an MD in the office; Equipment — which, in our case, is a cardiac monitor, and bag and mask; Supplies — such as IV fluid, needle, tape and gauze; Drugs — we stock oral and IV diphenhydramine, and IM/SQ epinephrine (1:1000); and Paperwork — the consent form, the symptoms checklist, and treatment flowsheets.

The protocol in our practice is symptom-based. For example, if there is nausea or vomiting, the protocol directs staff to provide an emesis basin, support, and monitor the patient for 30 minutes. In the event of mild hives or itching, the protocol calls for notification of the MD, the administration of oral diphenhydramine 25-50 mg, and monitoring until symptoms improve. For more severe hives or itching, we administer the drug IV.

In the event of the onset of respiratory symptoms, our protocol calls for us to record oxygen saturation and blood pressure, to call 911, to prepare the epinephrine for possible administration, and to get the doctor in the emergency room on the phone for guidance while awaiting arrival of the emergency team. Our entire protocol is available online at

The truth is that severe symptoms are rare, and fortunately, death from fluorescein angiography is reported to be only 1/220,000. But it is prudent to be prepared to deal with the more severe symptoms in the unlikely event they arise.

In terms of training, I think we physicians have to periodically review the management of anaphylaxis, and an excellent review is available in the article, “Office Approach to Anaphylaxis: Sooner Better than Later” by Stephen F. Kemp, which appeared in the Amercian Journal of Medicine (2007) 120, 664-668.

I do think it’s reasonable for nonphysicians to administer fluorescein, under the supervision of a physician.* In our case, it means that they have shown their ability to administer FA successfully 10 times under direct physician observation. After that, a physician must be present in the office and available to deal with any emergencies during administration. In our office, all staff (including doctors) maintain current CPR certification.

* OMIC warns that allowing unlicensed staff to inject may be illegal. See their risk management recommendations on FAs.




44 responses

11 02 2010
scott steidl

please send a copy of your anaphylaxis protocol



16 02 2010

I would be greatful if you could send me your anaphylaxis protocol. Thank you in advance.
Ophthalmologist from Slovenia

16 02 2010
Anthony Andrews

Please send me your protocol. I will let you know how it works in our practice.


Anthony Andrews, MD

18 02 2010

David. I would appreciate a copy of your anaphylaxis protocol.

24 02 2010

I found your article in the last issue of Retinal Physicians very interesting and useful for my practice. Please send me a copy of your fluorescein angiography protocol.

26 02 2010

Hi David
Please send me a copy of your anaphyaxis protocol.

1 03 2010
Diana W

Hi David,
Great website, can you please send me copy of your protocol?

14 03 2010

I’d love a copy of your protocol.

Thanks 🙂

15 03 2010

Very useful article. Please send a copy of your protocol. Thanks.

18 03 2010
Crystal Buchanan

Good day,
I would like to have a copy of your protocol.
Thank you!!

23 03 2010
Joyce Nelson

Hi David,

Please send me a copy of the anaphylaxis protocol. Thanks.


28 04 2010

Dear David,
I would appreciate a copy of your anaphylaxis protocol

1 06 2010

Hi, Could I have a copy of your protocol?


10 06 2010

Hi, I think you’re article addresses something very important. Could you please send me a copy of your anaphylaxis protocol. Thanks!

3 07 2010
Debbie Allen

Hi Dr. Khorram,
I enjoyed your discussion of anaphylaxis and IVFA protocols, but was a little confused by your incidence of anaphylaxis being one per 350, and I would like to clarify the definition of anaphylaxis in terms of signs/symptoms. For example, we wouldn’t consider vomiting alone (GI involvement) to be an anaphylactic response. I realize you mention involvement of any 2 of the 4 major organ systems would meet the definition. While we usually see itching and hives in about 5 per 1000 patients roughly, we really don’t see that many anaphylactic reactions (i.e. involving 2 major organ systems). Does your protocol discuss anaphylaxis in more detail? In any case, I would be very grateful if you could send me a copy.

As an ophthalmic technician in a major eye care centre, I’ve had the opportunity to perform over 10,000 IVFAs (some ICGs) and our protocol seems to be very similar to what you’ve reviewed in this blog. However, I’m always keen to improve our understanding and treatment plan in all aspects of patient care, and would enjoy very much reading your protocol.


11 07 2010

Hi Dr. David
Id like to have a copy of the article for Mx of Anaphylaxis during FFA.
I do FA in presence of an anaesthist after I had an death from Sudden Cardiac death during FA. The pt. had undergone FA on two previous occasions and the Fundus photographer recognised and took all steps but we lost the pt.
Howeverrare the event of severe reactions may seem, it would be prudent to be alert and review the emergency drugs before stsrting the FA.

15 07 2010
mehdi behnia

Hi david.
my question is, do you have any protocol for pre-op consultations for F/A patients? for example, in an IHD or CRF or CVA patient, do you seek consultations from internists bofore angiography? in my case, most of the internists whom i’ve consulted with are not caompletely familiar with complications of fluorescein injecion and i think their ideas are not so useful. what is your routine at present?


25 07 2010

I don’t typically consult internal medicine before a fluoroscein angiogram. I do check the blood pressure and oxygen saturation, as well as respiratory rate and pulse, though these are more often documented as a baseline in the event changes are seen during the FA.

24 07 2010
Dr Chris Kennedy

Helpful article. Please email me a copy of your protocol. Many thanks.

2 09 2010
jasbir mann

hi i work as specialist ophthalmic nurse and am currently writing nurse guidelines for FFA/ICG. I have developed a general health assessment covering baseline BP etc I would be most grateful if you could send me your protocol
many thanks jas

11 09 2010
Wes Heroman

I enjoyed the article. I recently joined a multi-subspecialty practice as their first retina doc, and my colleagues are eager to have an anaphylaxis protocol in place. If you could email yours I would greatly appreciate it.

12 09 2010

Thanks for all of the great blog posts. Would really like a copy of your protocol for our hospital.

Take care,

16 09 2010

Hey, thanks for blog. Can i get a copy of ur anaphaxis protocol?

11 11 2010

i found this article very impressive and informative.
can u plz email me the complete protocol
thanks in anticipation

24 11 2010

Dear Dr,
Thank you for a great article and blog. I would be grateful if you could please email me your protocol. Thanks in advance.

Kind regards,

9 12 2010
Christina Jain

Hi I am updating our protocol and would like to have copy of your complete protocol please.


22 12 2010

Could I please have a copy of your anaphylaxis protocol? Thanks

30 12 2010
Rebecca Dakuras

Can you please forward me a copy of your complete protocol. Thanks in advance. Rebecca

9 01 2011
Dr. Anya Brox

Hi Dr. Khorram,
Thanks for the great blog. Can you kindly send me a copy of your IVFA anaphylaxis protocol. We are in the process of developing one as well and it would be really informative. Much appreciated,

20 01 2011

Thanks for posting such an imp topic i would love to get a copy of your protocol hoping to do the best for patients thanks

14 02 2011
yoo jin bang

thanks for your useful information.
I wish you send me your protocol

14 03 2011
Marc Hirsch M.D.

Please kindly send a copy of for protocol for managing anaphylaxis from FA.

Thank you for your help.

Marc Hirsch

20 03 2011

Hi Dr. Khorram,
I would appreciate a copy of your anaphylaxis protocol.

22 03 2011

Dear David Khorram,

Thankyou for sharing your article. I found it very enlightning. Looking forward to reading your protocol.

Kind regards,

23 03 2011

Lovely discussion. Please send me a copy of the protocol. Thanks.

7 04 2011

Would you please send me you anaphylaxis protocol, thank you very much!

Hang sheng wang . MD

19 08 2011


Thank you very much for this useful information. Would you please send me a copy of your protocol?

25 10 2011
Dr.Mathew Varghese

Dear Sir,
I would much appreciate if you would send me a copy of the FFA PROTOCOL.

25 10 2011
Dr.Mathew Varghese

Dear Sir,
I would much appreciate if you would send me a copy of the FFA & ANAPHYLAXIS PROTOCOL.

16 11 2011
Landon Colling

Excellent information here. I am working on a protocol for our office. Can you send me a copy of yours?

Much appreciated!


1 12 2011
Pieter Lambrecht

could you also send me the anaphylaxis protocol?

5 12 2011

Dr, Khorram,
Great blog! I would very much appreciate a copy of the protocol, please.
Many thanks,

28 12 2011
Sami Kamjoo

Hi Dr. Khorram,

Can you kindly send me a copy of your anaphylaxis protocol?


2 10 2012

May I have a copy of your protocol?

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