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Subsections
Epinephrine Hazardous Material

{Inotropes & Pressors} or
{Asthma & COPD}

EPINEPHRINE

Adult Dosing

  • Cardiac arrest
    • 1 mg IV/IO q3-5min PRN (0.1 mg/mL soln), OR
    • Endotracheal: 2-2.5 mg (1 mg/mL soln) q3-5min PRN or until IV/IO access obtained
  • Bradycardia (2nd line)
    • 2-10 mcg/min; titrate to response
  • Anaphylaxis
    • 0.2-0.5 mg or 0.01 mg/kg (NMT 0.5 mg) IM/SC q5-15min PRN (1 mg/mL soln), OR
    • 0.1 to 0.25 mg IV q5-15min PRN (0.1-mg/mL soln)
    • Autoinjector (NMT 2 doses unless under medical supervision): 0.3 mg IM/SC in anterolateral thigh
  • Asthma Exacerbation
    • 0.3–0.5 mg SC q20min for 3 doses (1 mg/mL soln), OR
    • 0.01 mg/kg SC div into 3 doses (~0.3 mg each) given q20min
  • Hypotension, Septic Shock
    • 0.05-2 mcg/kg/min IV (in D5W or D5W/NaCl); titrate to desired MAP
      • May adjust in increments of 0.05-0.2 mcg/kg/min q10-15min
      • After stabilization, incrementally taper q10min

Pediatric Dosing

  • Cardiac Arrest, Bradycardia
    • 0.01 mg/kg (NMT 1 mg) IV/IO q3-5min PRN (0.1 mg/mL soln), OR
    • Endotracheal: 0.1 mg/kg (NMT 2.5 mg) q3-5min PRN (1 mg/mL soln)
  • Anaphylaxis
    • ≥30 kg: as adult
    • <30 kg: 0.01 mg/kg (NMT 0.3 mg) IM/SC q5-15 min PRN
    • May consider 0.01 mg/kg IV, if repeated doses required THEN
      • 0.1-1 mcg/kg/min IV, increased gradually to 1.5 mcg/kg/min to maintain BP
    • Autoinjector (NMT 2 doses unless under medical supervision)
      • ≥30 kg: as adult
      • 15-30 kg: 0.15 mg IM/SC in anterolateral thigh
      • 7.5-15 kg: 0.1 mg IM/SC in anterolateral thigh
  • Asthma Exacerbation
    • >12 yo: as adult
    • ≤12 yo: 0.01 mg/kg (NMT 0.3–0.5 mg) SC q20min for 3 doses (1 mg/mL soln)

Contraindications & Cautions

  • Contraindications
    • Hypersensitivity
    • Shock, heart dz or cardiac dilatation, closed-angle glaucoma, labor
    • In conjunction with local anesthetics, use in fingers, toes, ears, nose, or genitalia
  • Cautions
    • Cerebrovascular insufficiency, heart dz, angina, HTN, renal impairment
    • Allergic reactions w/ sulfite
    • Previous hospitalization for asthma
    • May aggravate angina pectoris or produce ventricular arrhythmias
      • Use caution in pts w/ heart diseases
    • Use caution for concomitant digitalis, mercurial diuretics, quinidine, or drugs which may sensitize the heart to arrhythmias
    • Use caution for concomitant MAOI or tricyclic antidepressants
    • Use caution for concomitant some general anesthetics (chloroform, trichloroethylene, cyclopropane, halothane)
    • Avoid injection into buttocks, digits, hands, or feet
    • Avoid extravasation into tissues; may cause local necrosis

Indications & Uses

  • Cardiac arrest, anaphylaxis, asthma, chronic glaucoma, hypotension associated w/ septic shock
  • Off-label: Stokes-Adams synd, hemostatic agent

Mechanism of Action

  • Strong beta-1 & alpha with moderate beta-2 effects resulting in incr cardiac output & heart rate, decr renal perfusion & PVR, & variable BP

Adverse Drug Reactions

  • Common: anxiety, restlessness, tremor, palpitations, pallor, N/V, headache, respiratory difficulties
  • Cardiovascular: angina, arrhythmias, HTN, tachyarrhythmia, tachycardia
  • Neurological: disorientation, impaired memory, panic, psychomotor agitation, sleepiness, tingling
  • Psychiatric: anxiety, restlessness
  • Other: Parkinson's disease pts may experience psychomotor agitation/worsening of sx's; blood sugar may inc in DM pts

Pregnancy and Lactation

  • Pregnancy
    • Risk Summary: limited data on acute effect in pregnancy
      • 1st-line Tx for anaphylaxis during pregnancy
      • May inhibit contractions during delivery; avoid during second-stage
      • Avoid when maternal BP >130/80
    • Human Data: limited data available
    • Animal Data: teratogenicity observed at >7x MRHD given for 3-4 days
  • Lactation
    • Risk Summary: unknown if present in human milk
      • 1st-line Tx for anaphylaxis in breastfeeding pts
    • Effect on production: unknown
    • Minimizing exposure: breastfeeding does not limit acute use
  • Reproductive Risk
    • Contraception: no specific recommendations
    • Fertility: decreased implantation observed at 40x MRHD in animal studies

Kinetics/Dynamics

  • Onset: asthma, SC <1 hr
  • Half-life: <5 min (IV)
  • Duration: 4 hr
  • Metabolism: by monoamine oxidase (MAO) & catechol-O-methyl transferase (COMT)
  • Metabolites: metadrenaline, sulfate conjugates and hydroxy derivatives of mandelic acid (inactive)
  • Excretion: urine

Overdose Management

Interactions

Trade Names

* = Discontinued

  • Dosing Strengths: (injection) 0.1 mg/mL, 0.5 mg/mL, 1 mg/ml
  • United States: Adrenalin; AsthmaHaler Mist*; AsthmaNefrin*; Ayerst Epitrate*; Bronitin Mist*; Bronkaid Mist Suspension*; Epifrin*; Epinal; Eppy/N*; Glaucon*; Medihaler-Epi*; Nephron*; Primatene Mist*; Primatene Mist Suspension*; S-2*; Sus-Phrine*; Vaponefrin*; microNefrin*
  • Canada: Bronkaid*; Dysne-Inhal*; Epi EZ*; Epifrin*; Medihaler-Epi*; Vaponefrin

* = Discontinued

IV Info

  • IV Incompatibilities
    • Solution: Na bicarb 5%, Inosol PSL, Inosol T/D5
    • Additive: aminophylline, hyaluronidase, mephentermine, Na bicarb
    • Syringe: Na bicarb
    • Y-site: ampicillin, thiopental
    • Not spec: 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, 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, vit B/C, warfarin
    • Not spec: meperidine
  • IV Preparation
    • Solution: 1 mg in 250 mL D5W or NS (4 mcg/mL); 15-60 mL/hr (1-4 mcg/min)
    • Administration: central line; infusion pump required
  • IV Administration
    • Do not mix w/alkaline solutions
    • Discard solution after 24 hr or if solution is discolored or contains precipitate
    • Keep solution in light-resistant container

Other Information

References

  1. ASHP Drug Compendium (Epinephrine;Autonomic Drugs, Alpha- and Beta-Adrenergic Agonists)
  2. FDA Monograph epinephrine (Adrenalin) https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/204200Orig1s009,204640Orig1s009lbl.pdf (Accessed December 2020)
  3. FDA Monograph epinephrine (EpiPen and EpiPen Jr) https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/019430s089lbl.pdf (Accessed December 2020)
  4. FDA Monograph epinephrine (AUVI-Q) https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/201739s015lbl.pdf (Accessed December 2020)
  5. Panchal AR, Berg KM, Hirsch KG, et al. 2019 AHA focused update on advanced cardiovascular life support: use of advanced airways, vasopressors, and extracorporeal cardiopulmonary resuscitation during cardiac arrest: an update to the AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2019; 140:e881–e894. doi: 10.1161/CIR.000000000000073
  6. National Asthma Education and Prevention Program (NAEPP). Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

Contributor(s)

  1. Freeman, James, PharmD
  2. Tambay, Ila, MPharm
  3. Reiner, Stefan, PharmD

Updated/Reviewed: December, 2020