epinephrine (Rx)

Frequency Not Defined

Angina

Anxiety

Apprehensiveness

Cardiac arrhythmias

Dizziness

Dyspnea

Flushing

Headache

Hypertension

Nausea

Nervousness

Pallor

Palpitations

Respiratory difficulties

Restlessness

Stress cardiomyopathy

Sweating

Tachycardia

Tremor

Vasoconstriction

Vomiting

Weakness

Postmarketing Reports

Necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene)

Contraindications

There are no contraindications for life-threatening situations

Nonanaphylactic shock

Narrow-angle glaucoma

Coadministration during genral anesthesia with halogenated hydrocarbons or cyclopropane

Labor

Situations where vasopressors may be contraindicated, including thyrotoxicosis, diabetes

Maternal blood pressure in excess of 130/80 mm Hg in hypertension and other cardiovascular disorders

Cautions

Use caution in patients with cardiac disease, angina (especially with history of CAD) or that are receiving drugs that sensitize the myocardium; treatment may induce cardiac arrhythmias

Pulmonary edema may occur as the result of cardiac stimulation and peripheral constriction

Decreased urine output may occur as the result of renal blood vessel constriction

Use caution in cerebrovascular insufficiency

Use with caution in patients with hypertension, diabetes mellitus, thyroid disease, prostatic hypertrophy, geriatric patients, pregnancy, and previous hospitalization for asthma

Rapid IV administration, although necessary in pulesless arrest, may cause death from cerebrovascular hemorrhage or cardiac arrhythmias

Patients that are sulfite-sensitive, should still be treated during a serious allergic reaction or other emergency even if products available contain sulfites

May cause worsening of symptoms in patients with Parkinson disease

Avoid extravasation; ensure proper needle or catheter placement prior to and during infusion

Correct blood volume depletion before administering any vasopressor

Rare cases of serious skin and soft tissue infections, including necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene), reported at injection site following injection for anaphylaxis; to decrease risk, do not inject into buttock; advise patients to seek medical care if they develop signs or symptoms of infection, such as persistent redness, warmth, swelling, or tenderness, at epinephrine injection site; cleansing with alcohol does not kill bacterial spores, and therefore, does not lower risk of infection

Multiple-dose vial not for ophthalmic use; contains chlorobutanol which may be harmful to corneal endothelium

Solutions must be diluted prior to intraocular use; other epinephrine products containing sodium bisulfite have been associated with corneal endothelial damage when used in the eye at undiluted concentrations (1 mg/mL)

Autoinjector is to be used in conjunction with immediate medical or hospital care; more than two sequential doses of epinephrine should only be administered under direct medical supervision

Pregnancy

Epinephrine crosses the placenta

Administration of epinephrine used during pregnancy only if the potential benefit justifies the potential risk to the fetus (fetal anoxia, spontaneous abortion, or both) Epinephrine is teratogenic in rabbits, mice, and hamsters dosed during organogenesis

Use with caution during labor and delivery; although epinephrine improves maternal hypotension associated with anaphylaxis, it may result in uterine vasoconstriction, decreased uterine blood flow, and fetal anoxia

Avoid epinephrine during second stage of labor; in dosage sufficient to reduce uterine contractions, the drug may cause a prolonged period of uterine atony with hemorrhage; avoid epinephrine in obstetrics when maternal blood pressure exceeds 130/80 mmHg

Lactation

Unknown whether epinephrine is excreted in human milk

Because many drugs are excreted in human milk, caution should be exercised when epinephrine is administered to a nursing woman

Mechanism of Action

Strong alpha-adrenergic effects, which cause an increase in cardio output and HR, a decrease in renal perfusion and PVR, and a variable effect on BP, resulting in systemic vasoconstriction and increased vascular permeability

Strong beta1- and moderate beta2-adrenergic effects, resulting in bronchial smooth muscle relaxation

Secondary relaxation effect on smooth muscle of stomach, intestine, uterus, and urinary bladder

Absorption

Onset: 5-10 min (SC); 1 min (inhalation)

Duration: 4 hr

Metabolism

Metabolized by MAO and COMT in adrenergic neuron

Metabolites: Metadrenaline, sulfate conjugates, and hydroxy derivatives of mandelic acid (inactive)

Elimination

Excretion: Urine

IV Incompatibilities

Solution: Na-bicarbonate 5%, Ionosol PSL, Ionosol T/D5

Additive: Aminophylline, hyaluronidase, mephentermine, Na-bicarbonate

Syringe: Na-bicarbonate(?)

Y-site: Ampicillin, thiopental

Not specified: Atropine, carbenicillin, diazepam, erythromycin, lidocaine

IV Compatibilities

Solution: D5W, D10W, dextrose-Ringer's, dextrose-saline, NS, LR, Ringer's

Additive: Amikacin, cimetidine, dobutamine, floxacillin, furosemide, metaraminol, ranitidine, verapamil

Syringe: Caffeine, doxapram, heparin, milrinone

Y-site: Amiodarone, atracurium, bivalirudin, CaCl2, Ca gluconate, cefpirome, cisatracurium, dexmedetomidine, diltiazem, dobutamine, dopamine, famotidine, fenoldopam, fentanyl, furosemide, heparin, Hextend, hydrocortisone Na succinate, hydromorphone, inamrinone, labetalol, levofloxacin, lorazepam, midazolam, milrinone, morphine SO4, nicardipine, nitroglycerin, norepinephrine, pancuronium, phytonadione, KCl, propofol, ranitidine, remifentanil, nitroprusside, tirofiban, vasopressin, vecuronium, vitamin B/C, warfarin

Not specified: Meperidine

IV Preparation

Dilute epinephrine in D5W or D5W 0.9% NaCl

Administration in saline solution alone is not recommended

Add 1 mL (1 mg) of epinephrine from its ampule to 1000 mL of a D5W containing solution

Each mL of this dilution contains 1 mcg of epinephrine

Solution: 1 mg in 250 mL D5W or NS (4 mcg/mL) to make up concentration of 15-60 mL/hr (1-4 mcg/min)

IV Administration

Correct blood volume depletion as fully as possible prior to administering any vasopressor

When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, epinephrine can be administered before and concurrently with blood volume replacement

Whenever possible, administer epinephrine infusions into a large vein

Avoid using a catheter tie-in technique, because the obstruction to blood flow around the tubing may cause stasis and increased local concentration of the drug

Central line; infusion pump required

Do not mix with alkaline solutions

Discard after 24 hours or if solution is discolored or contains precipitate

Store in light-resistant container

Intraocular Preparation

Epinephrine must be diluted prior to intraocular use

Dilute 1 mL of epinephrine 1 mg/mL (1:1000) in 100 to 1000 mL of an ophthalmic irrigation fluid to create an epinephrine concentration of 1:100,000 to 1:1,000,000 (10-1 mcg/mL)

Use the irrigating solution as needed for the surgical procedure

Intraocular Administration

After dilution in an ophthalmic irrigating fluid, inject intracamerally

SC/IM Administration

SC or IM administration only

Inject IM or SC into the anterolateral aspect of the thigh, through clothing if necessary

Do not administer autoinjector IV; administer only in outer thigh to ensure SC or IM administration

Do not inject into buttock, or into digits, hands, or feet

To minimize the risk of injection-related injury, instruct caregivers to hold the child's leg firmly in place and limit movement prior to and during injection when administering to young children

Discard remaining volume after dose has been administered

In conjunction with use, seek immediate medical or hospital care

Storage