Article Comprehensive Clinical Applications and Management of Epinep...

Epinephrine - StatPearls

National Institutes of Health (NIH) (.gov)

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by R Dalal · 2023 · Cited by 43 — [1] Off-label uses of epinephrine include, but are not limited to, ventricular fibrillation, pulseless ventricular tachycardia, asystole ...

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May 14, 2024 — † Off-label indication Revision Date: 05/14 ... Epinephrine hydrochloride injection in intact containers is stable until the labeled expiration ..

Drugs.comProfessional Brand names: Adrenaclick, Adrenalin, Auvi-Q, EpiPen Drug class: alpha- and beta-Adrenergic Agonists VA class: AU100 CAS number: 51-43-4

Medically reviewed by Drugs.com on Feb 21, 2024. Written by ASHP.

• Introduction
• Uses
• Dosage
• Warnings
• Interactions
• Stability
• FAQ

Warning

A standardized concentration for this drug has been established through Standardize 4 Safety (S4S), a national patient safety initiative to reduce medication errors, especially during transitions of care. The drug is included in a standard concentration list which may apply to an IV or oral compounded liquid formulation. For additional information, see the ASHP website [Web].

Introduction

Epinephrine is an endogenous catecholamine that is the active principle of the adrenal medulla; epinephrine acts directly on both α- and β-adrenergic receptors.

Uses for Epinephrine

Sensitivity Reactions

Drug of choice in the emergency treatment of severe acute anaphylactic reactions, including anaphylactic shock.

Used to relieve anaphylactic symptoms (e.g., urticaria, pruritus, angioedema, hypotension, respiratory distress) caused by reactions to drugs, contrast media, insect stings, foods (e.g., milk, eggs, fish, shellfish, peanuts, tree nuts), latex, or other allergens; also used for idiopathic or exercise-induced anaphylaxis.

Administer immediately by IM injection as soon as anaphylaxis is diagnosed or strongly suspected.

Administration by IM injection preferred, mainly because of safety considerations. However, IV administration may be necessary in extreme situations (e.g., anaphylactic shock, cardiac arrest, unresponsive or severely hypotensive patients who have failed to respond to multiple IM injections). Close hemodynamic monitoring is recommended during IV administration.

Also used for its vasopressor effects in the treatment of anaphylactic shock and cardiac arrest associated with anaphylaxis.

Manage cardiac arrest secondary to anaphylaxis with standard ACLS measures; consider alternative vasoactive drugs (e.g., vasopressin, norepinephrine) in patients who do not respond to epinephrine. (See ACLS and Cardiac Arrhythmias under Uses.) Consider other interventions (e.g., antihistamines, inhaled β2-adrenergic agents, IV corticosteroids) as clinically indicated.

Risk of paradoxical response to epinephrine in patients receiving β-adrenergic blocking agents; consider glucagon and/or ipratropium for treatment of anaphylaxis in these patients.

ACLS and Cardiac Arrhythmias

Used for its α-adrenergic effects to increase blood flow and facilitate return of spontaneous circulation (ROSC) during cardiac arrest. Principal benefits of the drug result from increases in aortic diastolic blood pressure and in coronary and cerebral blood flow during resuscitation.

High-quality CPR and defibrillation are the only proven interventions to increase survival to hospital discharge in ACLS. Other resuscitative efforts, including drug therapy, are considered secondary and should be performed without compromising the quality and timely delivery of chest compressions and defibrillation.

Principal goal of pharmacologic therapy during cardiac arrest is to facilitate ROSC, and epinephrine is the drug of choice for this use.

ACLS guidelines state that administration of epinephrine may be reasonable in adults with VF or pulseless VT resistant to initial CPR attempts and at least one defibrillation shock; optimal timing of administration (particularly in relation to defibrillation) not known and may vary based on patient-specific factors and resuscitation conditions. In adults with asystole or pulseless electrical activity (PEA), epinephrine may be administered as soon as feasible after onset of cardiac arrest.

Also may be used in the postresuscitation period to optimize BP, cardiac output, and systemic perfusion after ROSC.

Used during the periarrest period for treatment of symptomatic bradycardia in adults; although not a first-line drug, may be considered in patients who are unresponsive to atropine or as a temporizing measure while awaiting availability of a pacemaker.

Also used in the emergency treatment of infants and children with bradycardia and cardiopulmonary compromise (with a palpable pulse) when bradycardia persists despite ventilation, oxygenation, and chest compressions.

Drugs are rarely needed during resuscitation of neonates; because hypoxemia and inadequate lung inflation are common causes of bradycardia, establishing adequate ventilation is the most important corrective measure in these patients.

Also has been used in the treatment of syncope resulting from AV nodal block. However, permanent pacemaker implantation is the treatment of choice for third-degree and advanced second-degree AV nodal block (complete heart block).

Septic Shock

Used for treatment of hypotension associated with septic shock, generally as a second-line agent.

The Surviving Sepsis Campaign International Guidelines for Management of Sepsis and Septic Shock recommend norepinephrine as the first-line vasopressor of choice in adults with septic shock; if adequate BP not achieved, epinephrine may be added.

Vasopressor therapy is not a substitute for replacement of blood, plasma, fluids, and/or electrolytes. Correct blood volume depletion as fully as possible before administration of epinephrine.

Should not be used in cardiogenic shock (because it increases myocardial oxygen demand) or in hemorrhagic or traumatic shock.

Local Vasoconstriction

May be added to solutions of some local anesthetics to decrease the rate of vascular absorption (to localize and prolong the duration of anesthesia and decrease the risk of systemic toxicity).

Has been applied topically to control superficial bleeding from arterioles or capillaries in the skin, mucous membranes, or other tissues. Bleeding from larger vessels is not controllable by topical application.

Premature Labor

Has been used to relax uterine musculature and inhibit uterine contractions in premature labor† [off-label] (tocolysis); however, the cardiovascular and other adverse effects limit its usefulness. (See Pregnancy under Cautions.) Other β-agonists (e.g., terbutaline) preferred.

Bronchospasm

Has been used as an oral bronchodilator for symptomatic treatment of asthma. However, an epinephrine preparation for oral inhalation no longer commercially available in US.

While orally inhaled epinephrine was once widely used in the treatment of asthma, the drug has been replaced by more selective and rapid-acting agents (e.g., inhaled β2-adrenergic agonists).

Also has been used IV for treatment of severe asthma exacerbations; however, no evidence that the drug improves outcomes compared with selective inhaled β2-adrenergic agonists.

Upper GI Hemorrhage

Has been used as an endoscopic treatment modality (as a dilute solution injected into and around ulcer base) to produce tamponade and achieve hemostasis in patients with acute nonvariceal upper GI bleeding† [off-label]. Should not be used as monotherapy; use in combination with additional treatment modality (e.g., clips, thermocoagulation).

Epinephrine Dosage and Administration

Effective May 1, 2016, USP changed its labeling standard for all single-entity preparations of epinephrine injection, USP to require that dosage strengths be expressed only in terms of strength per mL (e.g., mg/mL). Use of ratio expressions (e.g., 1:1000 or 1:10,000) no longer is acceptable. Labeling change was prompted by numerous reports of serious medication errors caused by confusion with different ratio expressions.

Usually administered parenterally (by IM, sub-Q, or IV injection or by continuous IV infusion).

Select appropriate concentration and route of administration carefully; serious adverse effects (e.g., cerebral hemorrhage) have occurred after concentrated solutions of epinephrine intended for IM administration were administered IV. Generally administer IV only in extreme situations (e.g., septic or anaphylactic shock, cardiac arrest, or when patient is unresponsive to multiple IM injections). Always use dilute solutions of epinephrine (e.g., 0.1 mg/mL) when administering IV. Commercially available epinephrine solutions for IM or sub-Q injection are more concentrated (1 mg/mL) and should not be administered IV without dilution.

Also has been administered by intraosseous (IO) injection or infusion† [off-label] in the ACLS setting, generally when IV access not readily available; onset of action and systemic concentrations are comparable to those achieved with venous administration.

May be administered endotracheally if vascular access (IV or IO) cannot be established during cardiac arrest.

Also has been administered by intracardiac injection (into the left ventricular chamber) during cardiac arrest; however, this route of administration not recommended in current ACLS guidelines.

Solutions of epinephrine have been applied topically to the skin, mucous membranes, or other tissues for local hemostasis.

Also has been administered by oral inhalation in the treatment of asthma; however, an oral inhalation preparation no longer commercially available in the US.