epinephrine

IM:

High Alert

SC: IV: Severe allergic reactions.
IV: Hypotension associated with septic shock.
Inhaln: Upper airway obstruction and croup (racemic epinephrine).Temporary relief of mild symptoms of intermittent asthma (over-the-counter).

Local/Spinal

Adjunct in the localization/prolongation of anesthesia.

Unlabeled Use:

IV, Intracardiac, Intratracheal, Intraosseous (part of advanced cardiac life support [ACLS] and pediatric advanced life support [PALS] guidelines)

Cardiac arrest.
SC: Reversible airway disease due to asthma or COPD.

Action ⬆ ⬇

Results in the accumulation of cyclic adenosine monophosphate (cAMP) at beta-adrenergic receptors.
Affects both beta₁(cardiac)-adrenergic receptors and beta₂(pulmonary)-adrenergic receptor sites.
Produces bronchodilation.
Also has alpha-adrenergic agonist properties, which result in vasoconstriction.
Inhibits the release of mediators of immediate hypersensitivity reactions from mast cells.

Therapeutic effects:

Bronchodilation.
Maintenance of heart rate and BP.
Localization/prolongation of local/spinal anesthetic.

Pharmacokinetics ⬆ ⬇

Absorption: IV administration results in complete bioavailability; well absorbed following SUBQ administration; some absorption may occur following repeated inhalation of large doses.

Distribution: Does not cross the blood-brain barrier; crosses the placenta and enters breast milk.

Metabolism/Excretion: Action is rapidly terminated by metabolism and uptake by nerve endings.

Half-Life: Unknown.

Time/Action Profile ⬆ ⬇

(bronchodilation)

ROUTE	ONSET	PEAK	DURATION
Inhaln	1 min	unknown	1–3 hr
SUBQ	5–10 min	20 min	<1–4 hr
IM	6–12 min	unknown	<1–4 hr
IV	rapid	20 min	20–30 min

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity to adrenergic amines;
Some products may contain bisulfites and should be avoided in patients with known hypersensitivity or intolerance.

Use Cautiously in:

Cardiac disease (angina, tachycardia, MI);
Hypertension;
Hyperthyroidism;
Parkinson's disease;
Pheochromocytoma;
Diabetes;
Cerebral arteriosclerosis;
Glaucoma (except for ophthalmic use);
Excessive use may lead to tolerance and paradoxical bronchospasm (inhaler);
OB: Use during pregnancy only if potential maternal benefit justifies potential fetal risk;
Lactation: High IV doses of epinephrine might milk production or letdown. Low-dose epidural, topical, inhaled, or ophthalmic epinephrine are unlikely to interfere with breastfeeding;
Pedi: Children 12 yr (over-the-counter product only)
Geri: Older adults more susceptible to adverse reactions; may require dose.

Adv. Reactions/Side Effects ⬆ ⬇

CV: angina, arrhythmias, hypertension, tachycardia

Derm: skin and soft tissue infections (including necrotizing fasciitis and myonecrosis)

Endo: hyperglycemia

GI: nausea, vomiting

GU: renal impairment

Neuro: nervousness, restlessness, tremor, headache, insomnia

Resp: PARADOXICAL BRONCHOSPASM (WITH EXCESSIVE USE OF INHALERS), pulmonary edema

Interactions ⬆ ⬇

Drug-drug:

Concurrent use with other adrenergic agents will have additive adrenergic side effects.
Use with MAO inhibitors may lead to hypertensive crisis.
Beta blockers may negate therapeutic effect.
Tricyclic antidepressants enhance pressor response to epinephrine.

Drug-Natural Products:

Use with caffeine-containing herbs (cola nut, guarana, mate, tea, coffee) ↑ stimulant effect.

Route/Dosage ⬆ ⬇

SC IM (Adults and Children ≥30 kg): Severe anaphylaxis: 0.3–0.5 mg (single dose not to exceed 0.5 mg); may repeat every 10–15 min as needed.
SC (Children <30 kg): Severe anaphylaxis: 0.01 mg/kg (not to exceed 0.3 mg/dose); may repeat every 10–15 min as needed; Auvi-Q or Symjepi (15–30 kg): 0.15 mg; may repeat if anaphylactic symptoms persist; Auvi-Q (7.5–15 kg): 0.1 mg; may repeat if anaphylactic symptoms persist.
IV (Adults ): Severe anaphylaxis: 0.1–0.25 mg every 5–15 min; may be followed by 1–4 mcg/min continuous infusion; Cardiopulmonary resuscitation (ACLS guidelines): 1 mg every 3–5 min; Bradycardia (ACLS guidelines): 2–10 mcg/min continuous infusion; Hypotension associated with septic shock: 0.05–2 mcg/kg/min continuous infusion; titrate every 10–15 min by 0.05–0.2 mcg/kg/min to achieve desired mean arterial pressure.
IV (Children ): Severe anaphylaxis: 0.1 mg (less in younger children); may be followed by 0.1 mcg/kg/min continuous infusion (may be ↑ up to 1.5 mcg/kg/min); Symptomatic bradycardia/pulseless arrest (PALS guidelines): 0.01 mg/kg, may be repeated every 3–5 min, higher doses (up to 0.1–0.2 mg/kg) may be considered; may also be given by the intraosseous route. May also be given by the endotracheal route in doses of 0.1–0.2 mg/kg diluted to a volume of 3–5 mL with normal saline followed by several positive pressure ventilations.
Inhaln
(Adults ): Inhalation solution: 1 inhalation of 1% solution; may be repeated after 1–2 min; additional doses may be given every 3 hr; Racepinephrine: Via hand nebulizer, 2–3 inhalations of 2.25% solution; may repeat in 5 min with 2–3 more inhalations, up to 4–6 times daily.
Inhaln
(Children >1 mo): 0.25–0.5 mL of 2.25% racemic epinephrine solution diluted in 3 mL normal saline.
Inhaln
(Adults and Children ≥12 yr): Over-the-counter inhaler: 1–2 inhalations every 4 hr as needed (max = 8 inhalations/day).
IV
(Neonates ): 0.01–0.03 mg/kg every 3–5 min as needed.
(Adults ): 0.3–0.5 mg.
Endotracheal
(Adults ): Cardiopulmonary resuscitation (ACLS guidelines): 2–2.5 mg.
(Adults and Children ≥6 yr): Nasal decongestant: Apply 1% solution as drops, spray, or with a swab.
Intraspinal
(Adults and Children ): 0.2–0.4 mL of 1:1000 solution.
With Local Anesthetics
(Adults and Children ): Use 1:200,000 solution with local anesthetic.

Availability ⬆ ⬇

(Generic available)

Inhalation aerosol: 0.125 mg/inhalation (160 metered inhalations)^OTC
Inhalation solution (racepinephrine): 2.25%
Intranasal solution: 1 mg/mL (1:1000)
Premixed infusion: 2 mg/250 mL 0.9% NaCl; 4 mg/250 mL 0.9% NaCl; 5 mg/250 mL 0.9% NaCl; 8 mg/250 mL 0.9% NaCl; 10 mg/250 mL 0.9% NaCl
Solution for injection: 1 mg/mL (1:1000)
Solution for injection (autoinjectors) (Adrenaclick, Auvi-Q, EpiPen): 0.1 mg/0.1 mL (1:1000); 0.15 mg/0.15 mL (1:1000); 0.15 mg/0.3 mL (1:2000); 0.3 mg/0.3 mL (1:1000)
Solution for injection (prefilled syringes): 0.1 mg/mL (1:10,000); 0.15 mg/0.3 mL (1:2000); 0.3 mg/0.3 mL (1:1000)

Assessment ⬆ ⬇

Monitor IV infusion site for extravasation (cold, hard, pallid appearance). If blanching occurs, may change infusion site to allow effects of local vasoconstriction to subside. If extravasation occurs, infiltrate area liberally with 10 mL to 15 mL of 0.9% NaCl with 5 mg–10 mg of phentolamine using a syringe with a fine needle within 12 hr of extravasation. Local hyperemic changes are immediate.
Bronchodilator: Assess lung sounds, respiratory pattern, pulse, and BP before administration and during peak of medication. Note amount, color, and character of sputum produced, and notify health care professional of abnormal findings.
Monitor pulmonary function tests before and periodically during therapy.
Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold medication and notify health care professional immediately.
- Observe patient for drug tolerance and rebound bronchospasm. Patients requiring more than 3 inhalation treatments in 24 hr should be under close supervision. If minimal or no relief is seen after 3–5 inhalation treatments within 6–12 hr, further treatment with aerosol alone is not recommended.
- Assess for hypersensitivity reaction (rash; urticaria; swelling of the face, lips, or eyelids). If condition occurs, withhold medication and notify health care professional immediately.
Vasopressor: Monitor BP, pulse, ECG, and respiratory rate frequently during IV administration. Continuous ECG, hemodynamic parameters, and urine output should be monitored continuously during IV administration.
- Monitor for chest pain, arrhythmias, heart rate >110 bpm, and hypertension. Consult health care professional for parameters of pulse, BP, and ECG changes for adjusting dose or discontinuing medication.
Shock: Assess volume status. Correct hypovolemia prior to administering epinephrine IV.
Nasal Decongestant: Assess for nasal and sinus congestion prior to and periodically during therapy.

Lab Test Considerations:

May cause transient ↓ in serum potassium concentrations with nebulization or at higher than recommended doses.
- May cause an ↑ in blood glucose and serum lactic acid concentrations.

Toxicity and Overdose:

Symptoms of overdose include persistent agitation, chest pain or discomfort, decreased BP, dizziness, hyperglycemia, hypokalemia, seizures, tachyarrhythmias, persistent trembling, and vomiting.
- Treatment includes discontinuing adrenergic bronchodilator and other beta-adrenergic agonists and symptomatic, supportive therapy. Cardioselective beta blockers are used cautiously because they may induce bronchospasm.

Implementation ⬆ ⬇

Do not confuse epinephrine with ephedrine.
Patient harm or fatalities have occurred from medication errors with epinephrine. Epinephrine is available in various concentrations, strengths, and percentages and used for different purposes. Packaging labels may be confused or products incorrectly diluted. Dilutions should be prepared by a pharmacist. IV doses should be expressed in milligrams not ampules, concentration, or volume. Prior to administration, have second practitioner independently check original order, dose calculations, concentration, route of administration, and infusion pump settings.
Medication should be administered promptly at the onset of bronchospasm.
- Use a tuberculin syringe with a 26-gauge ½-in. needle for SUBQ injection to ensure that correct amount of medication is administered.
- Tolerance may develop with prolonged or excessive use. Effectiveness may be restored by discontinuing for a few days and then readministering.
- Do not use solutions that are pinkish or brownish or that contain a precipitate.
- For anaphylactic shock, volume replacement should be administered concurrently with epinephrine. Antihistamines and corticosteroids may be used in conjunction with epinephrine.
IM: SC: Administer into anterolateral thigh, through clothing if necessary for anaphylaxis. Hold child's leg firmly to limit movement during injection to prevent lacerations, bent needles, and broken/embedded needles. Avoid injecting into gluteal muscle; may not be effective for anaphylaxis and may cause infection. Medication can cause irritation of tissue. Rotate injection sites to prevent tissue necrosis. Massage injection sites well after administration to enhance absorption and to decrease local vasoconstriction. Avoid IM administration in gluteal muscle.
Inhaln: When using epinephrine inhalation solution, 10 drops of 1% base solution should be placed in the reservoir of the nebulizer.
- The 2.25% inhalation solution of racepinephrine must be diluted for use in the combination nebulizer/respirator.
- Allow 1–2 min to elapse between inhalations of epinephrine inhalation solution to make certain the second inhalation is necessary.
- When epinephrine is used concurrently with corticosteroid or ipratropium inhalations, administer bronchodilator first and other medications 5 min apart to prevent toxicity from inhaled fluorocarbon propellants.
Endotracheal: Epinephrine can be injected directly into the bronchial tree via the endotracheal tube if the patient has been intubated. Perform 5 rapid insufflations; forcefully administer 10 mL containing 2–2.5 mg epinephrine (1 mg/mL) directly into tube; follow with 5 quick insufflations.

IV Administration:

Diluent: The 1:10,000 solution can be administered undiluted. Dilute 1 mg (1 mL) of a 1:1000 solution in 9 mL of 0.9% NaCl to prepare a 1:10,000 solution.Concentration: 0.1 mg/mL (1:10,000).
Diluent: Dilute 1 mg (1 mL) of a 1:1000 solution in 250 mL of D5W or 0.9% NaCl. Protect from light. Infusion stable for 24 hr.Concentration: 4 mcg/mL.
Rate: See Route/Dosage section. Titrate to response (BP, heart rate, respiratory rate).

Patient/Family Teaching ⬆ ⬇

Instruct patient to take medication exactly as directed. If on a scheduled dosing regimen, take a missed dose as soon as possible; space remaining doses at regular intervals. Do not double doses. Caution patient not to exceed recommended dose; may cause adverse effects, paradoxical bronchospasm, or loss of effectiveness of medication.
- Instruct patient to contact health care professional immediately if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or chest pain.
- Advise patient to consult health care professional before taking any OTC medications or alcoholic beverages concurrently with this therapy. Caution patient also to avoid smoking and other respiratory irritants.
- Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
Inhaln: Review correct administration technique (aerosolization, IPPB) with patient.
- Do not spray inhaler near eyes.
- Advise patient to use bronchodilator first if using other inhalation medications, and allow 5 min to elapse before administering other inhalant medications, unless otherwise directed.
- Advise patient to rinse mouth with water after each inhalation dose to minimize dry mouth.
- Advise patient to maintain adequate fluid intake (2000–3000 mL/day) to help liquefy tenacious secretions.
- Advise patient to consult health care professional if respiratory symptoms are not relieved or worsen after treatment or if chest pain, headache, severe dizziness, palpitations, nervousness, or weakness occurs.
Autoinjector: Instruct patients using auto-injector for anaphylactic reactions to remove gray safety cap, placing black tip on thigh at right angle to leg. Press hard into thigh until auto-injector functions, hold in place for 10 sec, remove, and discard properly. Massage injected area for 10 sec. Pedi: Teach parents or caregivers signs and symptoms of anaphylaxis, how to use auto-injector safely, and to get the child to a hospital as soon as possible. Instruct parents or caregivers to teach child how to manage his or her allergy, how to self-inject, and what to do in an emergency. For children too young to self-inject and who will be separated from parent, tell parents to always discuss allergy and use of auto-injector with responsible adult.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇