Subcutaneous Use in the Setting of Status Asthmaticus is No Longer Recommended
Hemoptysis During Bronchoscopy (see Hemoptysis, [[Hemoptysis]] and Bronchoscopy, [[Bronchoscopy]])
Clinical Efficacy
Maintenance of Mydriasis During Ocular Surgery
May Be Used for this Indication
Post-Extubation Laryngeal Edema/Stridor (see Stridor, [[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, [[Sepsis]] and Hypotension, [[Hypotension]])
Intramuscular (IM) (see Anaphylaxis, [[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, [[Stridor]])
Nebulized Racemic Epinephrine: 1 mg in 5 mL of normal saline
Hemoptysis During Bronchoscopy (see Hemoptysis, [[Hemoptysis]] and Bronchoscopy, [[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, [[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, [[Nitroglycerin]]): apply a 1 inch strip to the affected site
Drug Interactions
Spironolactone (Aldactone) (see Spironolactone, [[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, [[Monoamine Oxidase Inhibitors]]): may enhance the hypertensive effect of vasopressors (epinephrine, etc) and other sympathomimetics
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]
