Patients who respond to therapy require observation, and symptoms may recur in some patients. Although there is no documented evidence defining the optimum length of observation time, some people with anaphylaxis may have one of two unusual patterns of symptoms: biphasic anaphylaxis, a syndrome in which symptoms resolve initially and then recur, usually within 1 to 8 hours but as long as 72 hours later; and protracted anaphylaxis, which may persist for up to 48 hours after treatment. The expert panel convened by ACAAI and ACEP concurred that patients who should be held for longer observation include those who:

Have hypotension

Required more than one epinephrine injection for resolution of symptoms

Ingested the suspected allergen

Also have asthma