Drug Name
Generic Name : epinephrine (adrenaline), epinephrine bitartrate, epinephrine borate, epinephrine hydrochloride
Brand Name:
- Aerosol: Primatene Mist
- Ophthalmic solution: Epinal
- Injection, OTC nasal solution: Adrenalin Chloride
- Insect-sting emergencies: EpiPen Auto-Injector (delivers 0.3 mg IM adult dose), EpiPen Jr. Auto-Injector (delivers 0.15 mg IM for children)
- OTC solutions for nebulization: AsthmaNefrin, microNefrin, Nephron, S2
Classification: Sympathomimetic, Alpha-adrenergic agonist, Beta1- and beta2-adrenergic agonist, Cardiac stimulant, Vasopressor, Bronchodilator, Antasthmatic, Nasal decongestant, Mydriatic
Pregnancy Category C
Dosage & Route
ADULTS
Epinephrine injection
- Cardiac arrest: 0.5–1 mg (5–10 mL of 1:10,000 solution) IV or by intracardiac injection into left ventricular chamber; during resuscitation, 0.5 mg q 5 min.
Intraspinal
0.2–0.4 mL of a 1:1,000 solution added to anesthetic spinal fluid mixture.
- Other use with local anesthetic: Concentrations of 1:100,000–1:20,000 are usually used.
1:1,000 solution
- Respiratory distress: 0.3–0.5 mL of 1:1,000 solution (0.3–0.5 mg), subcutaneously or IM, q 20 min for 4 hr.
1:200 suspension (for subcutaneous administration only)
- Respiratory distress: 0.1–0.3 mL (0.5–1.5 mg) subcutaneously.
Inhalation (aerosol)
- Begin treatment at first symptoms of bronchospasm. Individualize dosage. Wait 1–5 min between inhalations to avoid overdose.
Inhalation (nebulization)
- Place 8–15 drops into the nebulizer reservoir. Place nebulizer nozzle into partially opened mouth. Patient inhales deeply while bulb is squeezed one to three times. If no relief in 5 min, give 2–3 additional inhalations. Use four to six times per day usually maintains comfort.
Topical nasal solution
- Apply locally as drops or spray or with a sterile swab, as required.
Ophthalmic solution
- Vasoconstriction, mydriasis: Instill 1–2 drops into the eye or eyes; repeat once if necessary.
PEDIATRIC PATIENTS
Epinephrine injection
- 1:1,000 solution, children and infants except premature infants and full-term newborns: 0.01 mg/kg or 0.3 mL/m2 (0.01 mg/kg or 0.3 mg/m2) subcutaneously q 20 min (or more often if needed) for 4 hr. Do not exceed 0.5 mL (0.5 mg) in a single dose.
- 1:200 suspension, infants and children (1 mo–1 yr): 0.005 mL/kg (0.025 mg/kg) subcutaneously.
- Children < 30 kg: Maximum single dose is 0.15 mL (0.75 mg). Administer subsequent doses only when necessary and not more often than q 6 hr.
Topical nasal solution
- > 6 yr: Apply locally as drops or spray or with a sterile swab, as required.
Ophthalmic solutions
- Safety and efficacy for use in children not established.
GERIATRIC PATIENTS OR PATIENTS WITH RENAL FAILURE
- Use with caution; patients > 60 yr are more likely to develop adverse effects.
Therapeutic actions
- Epinephrine, an active principle of the adrenal medulla, is a direct-acting sympathomimetic. It stimulates α- and β-adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation and dilation of skeletal muscle vasculature. It is frequently added to local anaesthetics to retard diffusion and limit absorption, to prolong the duration of effect and to lessen the danger of toxicity.
Indications
- IV: In ventricular standstill after all other measures have failed to restore circulation, given by trained personnel by intracardiac puncture and intramyocardial injection; treatment and prophylaxis of cardiac arrest and attacks of transitory AV heart block with syncopal seizures (Stokes-Adams syndrome); syncope due to carotid sinus syndrome; acute hypersensitivity (anaphylactoid) reactions, serum sickness, urticaria, angioneurotic edema; in acute asthmatic attacks to relieve bronchospasm not controlled by inhalation or subcutaneous injection; relaxation of uterine musculature; additive to local anesthetic solutions for injection to prolong their duration of action and limit systemic absorption
- Injection: Relief from respiratory distress of bronchial asthma, chronic bronchitis, emphysema, other COPDs
- Aerosols and solutions for nebulization: Temporary relief from acute attacks of bronchial asthma, COPD
- Topical nasal solution: Temporary relief from nasal and nasopharyngeal mucosal congestion due to a cold, sinusitis, hay fever, or other upper respiratory allergies; adjunctive therapy in middle ear infections by decreasing congestion around eustachian ostia
- 0.1% ophthalmic solution: Conjunctivitis, during eye surgery to control bleeding, to produce mydriasis
Adverse effects
- CNS effects; GI disturbances; epigastric pain; CV disorders; difficulty in micturition with urinary retention; dyspnoea; hyperglycaemia; sweating; hypersalivation; weakness, tremors; coldness of extremities; hypokalaemia. Gangrene, tissue necrosis and sloughing (extravasation) when used in addition to local anaesthetics. Eye drops: Severe smarting, blurred vision, photophobia; naso-lachrymal ducts obstruction. Oedema, hyperaemia and inflammation of the eyes with repeated administration.
Contraindications
- Preexisting hypertension; occlusive vascular disease; angle-closure glaucoma (eye drops); hypersensitivity; cardiac arrhythmias or tachycardia. When used in addition to local anaesthetics: Procedures involving digits, ears, nose, penis or scrotum.
Nursing considerations
Assessment
- History: Allergy or hypersensitivity to epinephrine or components of drug preparation; narrow-angle glaucoma; shock other than anaphylactic shock; hypovolemia; general anesthesia with halogenated hydrocarbons or cyclopropane; organic brain damage, cerebral arteriosclerosis; cardiac dilation and coronary insufficiency; tachyarrhythmias; ischemic heart disease; hypertension; renal impairment; COPD; diabetes mellitus; hyperthyroidism; prostatic hypertrophy; history of seizure disorders; psychoneuroses; labor and delivery; lactation; contact lens use, aphakic patients (ophthalmic preparations)
- Physical: Weight; skin color, T, turgor; orientation, reflexes, IOP; P, BP; R, adventitious sounds; prostate palpation, normal urine output; urinalysis, renal function tests, blood and urine glucose, serum electrolytes, thyroid function tests, ECG
Interventions
- WARNING: Use extreme caution when calculating and preparing doses; epinephrine is a very potent drug; small errors in dosage can cause serious adverse effects. Double-check pediatric dosage.
- Use minimal doses for minimal periods of time; “epinephrine-fastness” (a form of drug tolerance) can occur with prolonged use.
- Protect drug solutions from light, extreme heat, and freezing; do not use pink or brown solutions. Drug solutions should be clear and colorless (does not apply to suspension for injection).
- Shake the suspension for injection well before withdrawing the dose.
- Rotate subcutaneous injection sites to prevent necrosis; monitor injection sites frequently.
- WARNING: Keep a rapidly acting alpha-adrenergic blocker (phentolamine) or a vasodilator (a nitrate) readily available in case of excessive hypertensive reaction.
- WARNING: Have an alpha-adrenergic blocker or facilities for intermittent positive pressure breathing readily available in case pulmonary edema occurs.
- WARNING: Keep a beta-adrenergic blocker (propranolol; a cardioselective beta-adrenergic blocker, such as atenolol, should be used in patients with respiratory distress) readily available in case cardiac arrhythmias occur.
- Do not exceed recommended dosage of inhalation products; administer pressurized inhalation drug forms during second half of inspiration, because the airways are open wider and the aerosol distribution is more extensive. If a second inhalation is needed, administer at peak effect of previous dose, 3–5 min.
- Use topical nasal solutions only for acute states; do not use for longer than 3–5 days, and do not exceed recommended dosage. Rebound nasal congestion can occur after vasoconstriction subsides.
Teaching points
- Do not exceed recommended dosage; adverse effects or loss of effectiveness may result. Read the instructions that come with respiratory inhalant products, and consult your health care provider or pharmacist if you have any questions.
- To give eye drops: Lie down or tilt head backward, and look up. Hold dropper above eye; drop medicine inside lower lid while looking up. Do not touch dropper to eye, fingers, or any surface. Release lower lid; keep eye open, and do not blink for at least 30 seconds. Apply gentle pressure with fingers to inside corner of the eye for about 1 minute; wait at least 5 minutes before using other eye drops.
- You may experience these side effects: Dizziness, drowsiness, fatigue, apprehension (use caution if driving or performing tasks that require alertness); anxiety, emotional changes; nausea, vomiting, change in taste (eat frequent small meals); fast heart rate. Nasal solution may cause burning or stinging when first used (transient). Ophthalmic solution may cause slight stinging when first used (transient); headache or brow ache (only during the first few days).
- Report chest pain, dizziness, insomnia, weakness, tremor or irregular heart beat (respiratory inhalant, nasal solution), difficulty breathing, productive cough, failure to respond to usual dosage (respiratory inhalant), decrease in visual acuity (ophthalmic).