epinephrine

ep-i-NEF-rin

Therapeutic Classification: antiasthmatics, bronchodilators, vasopressors

Pharmacologic Classification: adrenergics

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.

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 HR and BP.
Localization/prolongation of local/spinal anesthetic.

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

Distribution: Does not cross the blood-brain barrier.

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

Half-Life: Unknown.

(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
Intranasal	5–10 min	20–30 min	1 hr

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 disease;
Pheochromocytoma;
Diabetes;
Cerebral arteriosclerosis;
Glaucoma (except for ophthalmic use);
Excessive use may lead to tolerance and paradoxical bronchospasm (inhaler);
Structural or anatomic nasal conditions (intranasal only);
OB: Use during pregnancy only if potential maternal benefit justifies potential fetal risk; use for anaphylaxis should not be delayed in pregnancy;
Lactation: High IV doses of epinephrine might ↓ milk production or letdown. Low-dose epidural, topical, inhaled, intranasal, or ophthalmic epinephrine are unlikely to interfere with breastfeeding;
Pedi: Safety and effectiveness not established in children <12 yr (over-the-counter product only) or <15 kg (intranasal only);
Geri: Older adults more susceptible to adverse reactions; may require ↓ dose.

CV: angina, arrhythmias, hypertension, tachycardia

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

EENT: intranasal paresthesia (nasal spray), nasal discomfort (nasal spray), throat irritation (nasal spray), nasal congestion (nasal spray), nasal pruritus (nasal spray), rhinorrhea (nasal spray), sneezing (nasal spray)

Endo: hyperglycemia

GI: abdominal pain(nasal spray), nausea, vomiting

GU: renal impairment

Neuro: dizziness(nasal spray), headache, nervousness, restlessness, tremor, insomnia

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

Drug-drug:

Adrenergic agents will cause 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.
Use of intranasal product may ↑ absorption of other intranasal products and ↑ risk of toxicity.

Drug-Natural Products:

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

SC IM (Adults and Children ≥30 kg): Severe anaphylaxis: 0.3–0.5 mg (not to exceed 0.5 mg/dose); 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 ↑ up to 1.5 mcg/kg/min); Symptomatic bradycardia/pulseless arrest (PALS guidelines): 0.01 mg/kg; may repeat 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 repeat 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 (Adults and Children ≥12 yr): Over-the-counter inhaler: 1–2 inhalations every 4 hr as needed (max = 8 inhalations/day).
Inhaln (Children >1 mo): 0.25–0.5 mL of 2.25% racemic epinephrine solution diluted in 3 mL normal saline.
(Adults and Children ≥4 yr and ≥30 kg): One spray (2 mg) administered into one nostril; if no clinical improvement in 5 min, may administer another spray (2 mg) in same nostril.
(Adults and Children ≥4 yr and 15–<30 kg): One spray (1 mg) administered into one nostril; if no clinical improvement in 5 min, may administer another spray (1 mg) in same nostril.
IV Intratracheal (Neonates ): 0.01–0.03 mg/kg every 3–5 min as needed.
Intracardiac (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.

(Generic available)

Inhalation aerosol: 0.125 mg/inhalation (160 metered inhalations)^OTC
Inhalation solution (racepinephrine): 2.25%
Nasal spray: 1 mg/0.1 mL; 2 mg/0.1 mL
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)

Bronchodilator: Assess lung sounds, respiratory pattern, HR, and BP before administration and during peak. Note amount, color, and character of sputum produced.
Monitor pulmonary function tests before and periodically during therapy.
Observe for paradoxical bronchospasm (wheezing). If condition occurs, hold epinephrine and provide appropriate intervention.
- Assess for drug tolerance, especially if >3 inhalations in 24 hr needed. If minimal or no relief is in 6–12 hr, further treatment with aerosol alone is not recommended.
- Assess for hypersensitivity reaction (rash; urticaria; swelling of face, lips, or eyelids). If condition occurs, hold epinephrine.
Vasopressor: Monitor BP, HR, ECG, respiratory rate, and urine output continuously during IV administration. If chest pain, arrhythmia, HR >110 bpm, or hypertension occur, consider dose adjustment or discontinue epinephrine depending on severity of symptoms.
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 potassium with nebulization or at higher than recommended doses.
- May ↑ blood glucose and lactic acid.

Toxicity and Overdose:

Symptoms of overdose include persistent agitation, chest pain or discomfort, ↓ BP, dizziness, hyperglycemia, hypokalemia, seizures, tachyarrhythmia, 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.

Do not confuse epinephrine with ephedrine.
High Alert: 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 precipitates.
- For anaphylactic shock, volume replacement should be administered concurrently with epinephrine. Antihistamines and corticosteroids may be used in conjunction with epinephrine.
Administer one spray into either nostril. If no clinical improvement or symptoms worsen, administer 2nd dose to same nostril 5 min after first dose.
Inhaln: Place 10 drops of 1% base solution 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 2nd inhalation is necessary.
- When epinephrine is used concurrently with corticosteroid or ipratropium inhalations, administer bronchodilator 1st and other medications 5 min apart to prevent toxicity from inhaled fluorocarbon propellants.
IM: SC: Administer into anterolateral thigh, through clothing if necessary, for anaphylaxis. Hold 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. Rotate injection sites to prevent tissue irritation or necrosis. Massage injection sites well after administration to enhance absorption and ↓ local vasoconstriction.
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:

IV epinephrine is a vesicant. Central line administration is preferred; extravasation may cause severe ischemic necrosis. If central line is not available, may administer for <72 hr through a peripheral IV catheter placed in a large vein at a proximal site (e.g., in or proximal to antecubital fossa). If extravasation occurs, immediately stop infusion. Leave needle/cannula in place temporarily but do not flush the line. Gently aspirate extravasated solution; then remove needle/cannula. Elevate patient's extremity and apply dry warm compresses. Initiate phentolamine antidote for refractory cases in addition to supportive management. For phentolamine, dilute 5–10 mg in 10 mL of 0.9% NaCl and administer SUBQ into extravasation site as soon as possible after extravasation; if IV catheter remains in place, administer initial dose IV through the infiltrated catheter. May repeat in 60 min if patient remains symptomatic. Nitroglycerin 2% topical ointment (1-inch strip applied to site of ischemia to cover affected area; may repeat every 8 hr as necessary) or terbutaline may be used as alternatives to phentolamine. For terbutaline, for large areas of extravasation, dilute 1 mg in 10 mL of 0.9% NaCl and administer SUBQ into extravasation site; may repeat in 15 min if necessary; for small areas of extravasation, dilute 1 mg in 1 mL of 0.9% NaCl and administer 0.5 mg (0.5 mL) SUBQ into extravasation site; may repeat in 15 min if necessary.
IV Push: Diluent: 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).
Rate: Administer each 1 mg (10 mL) of a 1:10,000 solution over ≥1 min; more rapid administration may be used during cardiac resuscitation. Follow each dose with 20 mL IV saline flush.
Continuous Infusion: 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.
Y-Site Compatibility:
- alprostadil
- amikacin
- aminocaproic acid
- amiodarone
- amphotericin B liposomal
- angiotensin II
- anidulafungin
- argatroban
- arsenic trioxide
- ascorbic acid
- asparaginase
- atracurium
- atropine
- azithromycin
- aztreonam
- benztropine
- bivalirudin
- bleomycin
- buprenorphine
- butorphanol
- caffeine citrate
- calcium chloride
- calcium gluconate
- cangrelor
- carboplatin
- caspofungin
- cefazolin
- cefiderocol
- cefotaxime
- cefotetan
- cefoxitin
- ceftazidime
- ceftolozane/tazobactam
- ceftriaxone
- cefuroxime
- chloramphenicol
- chlorothiazide
- chlorpromazine
- cisatracurium
- cisplatin
- clindamycin
- cyanocobalamin
- cyclophosphamide
- cyclosporine
- cytarabine
- dactinomycin
- daptomycin
- daunorubicin
- dexamethasone
- dexmedetomidine
- dexrazoxane
- digoxin
- diltiazem
- diphenhydramine
- dobutamine
- docetaxel
- dopamine
- doxorubicin hydrochloride
- doxorubicin liposomal
- doxycycline
- edetate calcium disodium
- enalaprilat
- ephedrine
- epirubicin
- epoetin alfa
- eptifibatide
- eravacycline
- ertapenem
- erythromycin
- esmolol
- etoposide
- etoposide phosphate
- famotidine
- fentanyl
- fluconazole
- fludarabine
- folic acid
- foscarnet
- fosphenytoin
- furosemide
- gemcitabine
- gentamicin
- glycopyrrolate
- granisetron
- heparin
- hydrocortisone
- hydromorphone
- ibuprofen lysine
- idarubicin
- ifosfamide
- imipenem/cilastatin
- imipenem/cilastatin/relebactam
- irinotecan
- isavuconazonium
- isoproterenol
- ketamine
- ketorolac
- labetalol
- leucovorin
- levofloxacin
- lidocaine
- linezolid
- lorazepam
- magnesium sulfate
- mannitol
- meperidine
- meropenem
- meropenem/vaborbactam
- mesna
- methadone
- methotrexate
- methylprednisolone
- metoclopramide
- metoprolol
- metronidazole
- midazolam
- milrinone
- minocycline
- mitomycin
- mitoxantrone
- morphine
- moxifloxacin
- multivitamins
- mycophenolate
- nafcillin
- nalbuphine
- naloxone
- nicardipine
- nitroglycerin
- nitroprusside
- norepinephrine
- octreotide
- ondansetron
- oritavancin
- oxacillin
- oxaliplatin
- oxytocin
- paclitaxel
- palonosetron
- pamidronate
- papaverine
- pemetrexed
- penicillin G
- pentamidine
- phentolamine
- phenylephrine
- phytonadione
- piperacillin/tazobactam
- plazomicin
- potassium acetate
- potassium chloride
- procainamide
- prochlorperazine
- promethazine
- propranolol
- protamine
- pyridoxine
- remifentanil
- remimazolam
- rocuronium
- sildenafil
- sodium acetate
- succinylcholine
- sulbactam/durlobactam
- tacrolimus
- tedizolid
- theophylline
- thiamine
- thiotepa
- tigecycline
- tirofiban
- tobramycin
- topotecan
- vancomycin
- vasopressin
- vecuronium
- verapamil
- vinblastine
- vincristine
- vinorelbine
- voriconazole
- zoledronic acid
Y-Site Incompatibility:
- acyclovir
- alemtuzumab
- amphotericin B deoxycholate
- azathioprine
- carmustine
- clevidipine
- dacarbazine
- dantrolene
- diazepam
- diazoxide
- fluorouracil
- ganciclovir
- gemtuzumab ozogamicin
- indomethacin
- micafungin
- pentobarbital
- phenobarbital
- phenytoin
- sodium bicarbonate
- sulfamethoxazole/trimethoprim

Explain purpose and side effects of medication. Advise patient to read Patient Information before starting therapy.
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.
- Instruct patient to seek emergency care immediately if shortness of breath is not relieved, worsens, or is accompanied by diaphoresis, dizziness, palpitations, or chest pain.
- Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care provider before taking other medications or alcohol. Caution patient also to avoid smoking and other respiratory irritants.
- Advise women of reproductive potential to notify health care provider 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 1st 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.
Autoinjector or intranasal: Advise patient using epinephrine for anaphylaxis to always carry device with them. Instruct in appropriate administration and disposal. For use of autoinjector, instruct patient to remove gray safety cap, placing black tip on thigh at right angle to leg. Press hard into thigh until autoinjector functions, hold in place for 10 sec, remove, and discard properly. Massage injected area for 10 sec. For use of intranasal preparation, instruct patient to administer single dose in either nostril. If 2nd dose is needed, use same nostril 5 min after initial dose. Do not sniff during or after use. Pedi: Teach caregivers signs and symptoms of anaphylaxis, correct administration techniques, and to get the child to a hospital as soon as possible. Instruct caregivers to teach child how to manage their allergy, how to self-administer, and what to do in an emergency. For children too young to administer epinephrine and who will be separated from caregiver, tell caregivers to always discuss allergy and use of medication with responsible adult.

Prevention or relief of bronchospasm.
- Increase in ease of breathing.
- Prevention of bronchospasm or reduced frequency of acute asthma attacks in patients with chronic asthma.
- Prevention of exercise-induced asthma.
Reversal of signs and symptoms of anaphylaxis.
↑in cardiac rate and output, when used in cardiac resuscitation.
↑BP, when used as a vasopressor.
Localization of local anesthetic.
↓sinus and nasal congestion.

Adrenaclick, Adrenalin, ~~AsthmaNefrin,~~ Auvi-Q, EpiPen, Neffy, Primatene Mist, Symjepi, ~~Twin-Ject~~

Allerject, Anapen, Anapen Junior, Emerade, S-2 (racepinephrine)

section name header

Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇

Interactions ⬆ ⬇

Route/Dosage ⬆ ⬇

Availability ⬆ ⬇

Assessment ⬆ ⬇

Implementation ⬆ ⬇

Patient/Family Teaching ⬆ ⬇

Evaluation/Desired Outcomes ⬆ ⬇

US Brand Names ⬆ ⬇

Canadian Brand Names ⬆