Indications
Advanced Cardiac Life Support (ACLS) (see Advanced Cardiac Life Support)
- Indications
- Asystole (see Asystole)
- Bradycardia (see Sinus Bradycardia): symptomatic and unresponsive to atropine or pacing
- Pulseless Electrical Activity (PEA) (see Pulseless Electrical Activity)
- Pulseless Ventricular Tachycardia (VT) (see Ventricular Tachycardia)
- Ventricular Fibrillation (VF) (see Ventricular Fibrillation)
Asthma (see Asthma)
Clinical Utility
- Subcutaneous Use in the Setting of Status Asthmaticus is No Longer Recommended
Maintenance of Mydriasis During Ocular Surgery
Clinical Efficacy
- May Be Used for this Indication
Post-Extubation Laryngeal Edema/Stridor (see Stridor)
- Rationale
- Results in local vasoconstriction, decreasing laryngeal edema
- Clinical Efficacy
- Efficacy is Unclear
- Pediatric Trial of Dexamthasone and Nebulized Epinephrine in Laryngeal Edema (Int J Pediatr Otorhinolaryngol, 2009) [MEDLINE]: dexamethasone and L-epinephrine did not reduce the clinical progression of airway obstruction due to laryngeal edema in the early post-extubation period
Septic Shock/Hypotension (see Sepsis and Hypotension)
- Rationale
- XXXX
Pharmacology
Pharmacologic Effects at Adrenergic Receptors
- α1-Adrenergic Receptor Agonist (see α1-Adrenergic Receptor Agonists)
- Vascular Smooth Muscle α1-Adrenergic Receptors
- Mediate Vasoconstriction
- Vascular Smooth Muscle α1-Adrenergic Receptors
- β1-Adrenergic Receptor Agonist (see β1-Adrenergic Receptor Agonists)
- Cardiac β1-Adrenergic Receptors
- Mediate Increased Atrioventricular Nodal Conduction Velocity
- Mediate Increased Chronotropy
- Mediate Increased Inotropy
- Renal Juxtaglomerular Cell β1-Adrenergic Receptors
- Mediate Increased Renin Release
- Cardiac β1-Adrenergic Receptors
- β2-Adrenergic Receptor Agonist (see β2-Adrenergic Receptor Agonists)
- Bronchial Smooth Muscle β2-Adrenergic Receptors
- Mediate Bronchodilation
- Gastrointestinal β2-Adrenergic Receptors
- Mediate Slowing of Peristalsis
- Mediate Slowing of Secretions
- Hepatic β2-Adrenergic Receptors
- Mediate Gluconeogenesis
- Mediate Glycogenolysis
- Mediate Lipolysis
- Ocular Ciliary Muscle β2-Adrenergic Receptors
- Mediate Flow of Aqueous Humor
- Mediate Accommodation
- Uterine Muscle β2-Adrenergic Receptors
- Mediate Uterine Relaxation (Tocolysis)
- Urinary Bladder Detrusor Muscle β2-Adrenergic Receptors
- Mediate Detrusor Muscle Relaxation
- Vascular Smooth Muscle β2-Adrenergic Receptors
- Mediate Vasodilation
- Bronchial Smooth Muscle β2-Adrenergic Receptors
- β3-Adrenergic Receptor Agonist
- Adipose Tissue β3-Adrenergic Receptors
- Mediate Lipolysis
- Adipose Tissue β3-Adrenergic Receptors
Pharmacokinetics
- Half-Life: <5 min
- Distribution: epinephrine does not cross the blood-brain barrier
Metabolism
- Hepatic Metabolism of Circulating Epinephrine
- Urinary Excretion of Inactive Metabolites, Metanephrine, Sulfate and Hydroxy Derivatives of Mandelic Acid, and Small Amounts of Unchanged Drug
- Uptake by Adrenergic Neurons and Metabolism by Monoamine Oxidase (MAO) and Catechol-0-Methyltransferase
Administration
Advanced Cardiac Life Support (ACLS) (see Advanced Cardiac Life Support)
Asystole/Pulseless Electrical Activity (PEA)/Pulseless Ventricular Tachycardia (VT)/Ventricular Fibrillation
- Intravenous (IV): 1 mg (1:10,000 Dilution = 0.1 mg/mL) q3-5 min
- Intraosseous (IO): 1 mg (1:10,000 Dilution = 0.1 mg/mL)
- Intratracheal (via Endotracheal Tube): 2-2.5 mg in 10 ml normal saline (1:10,000 Dilution = 0.1 mg/mL) q3-5 min
- May Cause False-Negative Readings with Exhaled Carbon Dioxide (CO2) Detectors
Symptomatic Bradycardia (Unresponsive to Atropine and/or Pacing)
- Intravenous (IV) Infusion: 2-10 μg/min
Septic Shock/Hypotension (see Sepsis and Hypotension)
- Intravenous (IV) Infusion: 2-10 μg/min
- Route: central venous catheter (CVC) is preferred (see Central Venous Catheter)
Anaphylaxis (see Anaphylaxis)
- Intramuscular (IM) (see Anaphylaxis): 0.3 mg (1:1,000 Dilution = 1 mg/mL) into anterior middle third of the thigh
- Same Dose as Preloaded Epinephrine Injector Devices (EpiPen, Adrenaclick, Auvi-Q)
- Intravenous (IV): recommended only for patients with refractory hypotension and lack of response to multiple intramuscular epinephrine injections or if patient is in cardiopulmonary arrest
- Subcutaneous (SQ): no longer recommended (due to slower and less reliable absorption than intramuscular administration)
Post-Extubation Laryngeal Edema/Stridor (see Stridor)
- Nebulized Racemic Epinephrine (Racepinephrine): 1 mL of 2.25% racepinephrine (contains 11.25 mg, as 13.5 of racepinephrine HCl)
- Dilute in 3 mL of Normal Saline for Nebulization
Hemoptysis During Bronchoscopy (see Hemoptysis and Bronchoscopy)
- Intrabronchial (Topical Instillation via Bronchoscope)
- Dilute 10 mL of 1:10,000 Epinephrine (0.1 mg/mL) + 10 mL Normal Saline: yields 20 mL of 1:20,000 Epinephrine
- Instill 2 mL Intrabronchially (Via Bronchoscope) at a Time (Max Total Dose: 10 mL = 0.5 mg)
Dose Adjustment
- Hepatic: none
- Renal: none
Extravasation Management
- Epinephrine is a Vesicant: extravasation can cause tissue necrosis
- Technique to Manage Extravasation
- Discontinue Epinephrine Infusion and Gently Aspirate the Extravasated Solution
- Phentolamine (see Phentolamine): dilute 5-10 mg in 10-15 mL of normal saline and administer into extravasation site as soon as possible after extravasation
- Topical Nitroglycerin 2% Ointment (see Nitroglycerin): apply a 1 inch strip to the affected site
Drug Interactions
- Spironolactone (Aldactone) (see Spironolactone): spironolactone may decrease the vasoconstrictor effect of α/β-adrenergic agonists
- Inhalational Anesthetics: may increase the arrhythmogenic effect of epinephrine
- MAO Inhibitors (see Monoamine Oxidase Inhibitors): may enhance the hypertensive effect of vasopressors (epinephrine, etc) and other sympathomimetics
- Linezolid (Zyvox) (see Linezolid)
- Lurasidone (Latuda) (see Lurasidone): epinephrine may enhance the hypotensive effect of lurasidone
- Serotonin Norepinephrine Reuptake Inhibitors (SNRI) (see Serotonin-Norepinephrine Reuptake Inhibitors): SNRI’s may enhance the vasopressor effects of α/β-adrenergic agonists
Adverse Effects
Cardiovascular Adverse Effects
- Arrhythmias
- Clinical
- Atrial Fibrillation (AF) (see Atrial Fibrillation)
- Supraventricular Tachycardia (SVT) (see Supraventricular Tachycardia)
- Ventricular Tachycardia (VT) (see Ventricular Tachycardia)
- Clinical
- Exacerbation of Myocardial Ischemia (see Coronary Artery Disease)
- Clinical
- Acute Myocardial Infarction
- Chest Pain/Angina (see Chest Pain)
- Clinical
- Extravasation-Associated Tissue Necrosis
- Epidemiology: associated with intravenous administration
- Hypertension (see Hypertension)
- Palpitations (see Palpitations)
- QT Prolongation without Definite Association with Torsade (see Torsade)
- Sinus Tachycardia (see Sinus Tachycardia)
Dermatologic Adverse Effects
- Diaphoresis (see Diaphoresis)
Endocrinologic Adverse Effects
- Hyperglycemia (see Hyperglycemia)
Gastrointestinal Aderse Effects
- Nausea/Vomiting (see Nausea and Vomiting)
Neurologic Adverse Effects
- Anxiety (see Anxiety)
- Headache (see Headache)
- Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident)
- Tremor (see Tremor)
- Worsening of Parkinson’s Disease (see Parkinson’s Disease)
Pulmonary Adverse Effects
- Pulmonary Edema (see Pulmonary Edema)
- Pharmacology: due to peripheral vasoconstriction and cardiac stimulation
Renal Adverse Effects
- Decreased Urine Output
- Pharmacology
- Renal Vasoconstriction
- Pharmacology
- Lactic Acidosis (see Lactic Acidosis)
- Physiology: class effect (common to all catecholamines)
- Increased Glycolysis and Pyruvate Production
- Increased Lipolysis with Resultant Inhibition of Pyruvate Dehydrogenase: this prevents pyruvate from going through the Krebs cycle, resulting in pyruvate reduction to lactate
- Physiology: class effect (common to all catecholamines)
Rheumatologic/Orthopedic Adverse Effects
- Acute Limb Ischemia/Digital Ischemia (see Acute Limb Ischemia)
- Pharmcology: due to vasoconstriction
References
- Adrenaline administered via a nebulizer in adult patients with upper airway obstruction. Anaesthesia. 1995;50:35–6 [MEDLINE]
- The effect of epinephrine by nebulization on measures of airway obstruction in patients with acute severe croup. Intensive Care Med. 2008;34:138–47
- L-epinephrine and dexamethasone in postextubation airway obstruction: a prospective, randomized, double-blind placebo-controlled study. Int J Pediatr Otorhinolaryngol. 2009;73:1639–43 [MEDLINE]
- Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2013;10:CD006619 [MEDLINE]
- Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review. Crit Care. 2015 Sep 23;19:295. doi: 10.1186/s13054-015-1018-2 [MEDLINE]