Epinephrine (Adrenaline, Parenteral)
Indications
Epinephrine (Adrenaline, Parenteral) is used for:
Cardiac arrest;
Severe anaphylactic reaction;
Severe angioedema
Adult Dose
Cardiac arrest, by IV injection through a central line using epinephrine injection 1 in 10,000 (100 µg/mL), ADULT 1 mg (10 mL), repeated at 3-minute intervals if necessary
NOTE:
If central line not in place, same dose is given via peripheral vein, then flushed through with at least 20 mL sodium chloride 0.9% injection (to expedite entry into circulation). Different dilutions of epinephrine injection are used for different routes of administration
Anaphylaxis, by IM or SC injection of 1:1000 epinephrine injection, see Steps in the Management of Anaphylaxis for doses (see Note below).
Anaphylaxis, by slow IV injection of 1:10,000 epinephrine injection. This route should be reserved for severely ill patients when there is doubt about the adequacy of circulation and absorption from the intramuscular site, see Steps in the Management of Anaphylaxis for doses (see Note below).
NOTE:
Steps in the Management of Anaphylaxis - see Therapeutic Notes under section "Antiallergics and Drugs used in Anaphylaxis"
Epinephrine is given by subcutaneous or intramuscular injection. In extreme emergencies, where a more rapid effect is required, it may be given as a dilute solution (1 in 10,000 or 1 in 100,000) by slow intravenous injection or by slow intravenous infusion
Nigerian Standard Treatment Guidelines 2016 recommendations:
Blood transfusion reactions: 0.5 mL of 1:1000 solutions by subcutaneous injection (Combination therapy).
Child Dose
Anaphylaxis, by IM or SC injection of 1:1000 epinephrine injection, see Steps in the Management of Anaphylaxis for doses (see Note below).
Anaphylaxis, by slow IV injection of 1:10,000 epinephrine injection. This route should be reserved for severely ill patients when there is doubt about the adequacy of circulation and absorption from the intramuscular site, see Steps in the Management of Anaphylaxis for doses (see Note below).
NOTE:
Steps in the Management of Anaphylaxis - see Therapeutic Notes under section "Antiallergics and Drugs used in Anaphylaxis"
Epinephrine is given by subcutaneous or intramuscular injection. In extreme emergencies, where a more rapid effect is required, it may be given as a dilute solution (1 in 10,000 or 1 in 100,000) by slow intravenous injection or by slow intravenous infusion
Renal Dose
Administration
Do not use if the injection is discoloured or contains a precipitate.
Epinephrine is given by subcutaneous or intramuscular injection.
In extreme emergencies, where a more rapid effect is required, it may be given as a dilute solution (1 in 10,000 or 1 in 100,000) by slow intravenous injection or by slow intravenous infusion.
Inject intramuscular epinephrine into anterolateral aspect of thigh; do not inject into hands, feet, ears, nose, genitals or buttocks
Contra Indications
NOTE: The contraindications are relative as epinephrine is indicated for use in life-threatening emergencies.
Known hypersensitivity to epinephrine (adrenaline) or sympathomimetic amines.
Shock (non-anaphylactic).
Organic brain damage.
Narrow angle (congestive) glaucoma.
Conditions in which vasopressor drugs may be contraindicated, e.g., thyrotoxicosis, diabetes, in obstetrics when maternal blood pressure is in excess of 130/80 mm/Hg and in hypertension and other cardiovascular disorders. Except when epinephrine is used as admixture with local anesthetics to reduce absorption and prolong action.
Epinephrine may delay the second stage of labour by inhibiting spontaneous or oxytocin induced contractions of the pregnant human uterus.
Injection of epinephrine with local anaesthetics combination should be avoided in certain areas where there is danger of vasoconstriction causing sloughing of tissues (e.g. procedures involving fingers, toes, ears, nose or genitalia).
Avoid administration of epinephrine in patients anesthetized with cyclopropane, halothane or similar volatile general anesthetics as these agents increase cardiac irritability and may sensitize the myocardium to the arrhythmic action of sympathomimetic drugs
Precautions
Heart disease; Hypertension; Arrhythmias; Cerebrovascular disease; Hyperthyroidism; Diabetes mellitus
Angle-closure glaucoma
Second stage of labour
INTERACTIONS:
Severe anaphylaxis in patients on non-cardioselective beta-blockers for example, propranolol, may not respond to adrenaline injection calling for IV injection of salbutamol. Furthermore, adrenaline may cause severe hypertension in those receiving beta-blockers.
Patients on tricyclic antidepressants are considerably more susceptible to arrhythmias, calling for a much-reduced dose of adrenaline
Pregnancy-Lactation
Recommendations on the use of Epinephrine in Pregnancy & Lactation:
Teratogenicity has been reported with use in some animal studies. Epinephrine is not recommended during pregnancy but can be used as part of local anaesthesia during lactation (Briggs & Freeman, 2015; Schaefer et al., 2015).
References:
1. Briggs, G. G., & Freeman, R. K. (2015). Drugs in pregnancy and lactation: A reference guide to fetal and neonatal risk (Tenth edition). Wolters Kluwer/Lippincott Williams & Wilkins Health.
2. Schaefer, C., Peters, P., & Miller, R. K. (2015). Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment (Third Edition). Academic Press
Interactions
Severe anaphylaxis in patients on non-cardioselective beta-blockers for example, propranolol, may not respond to adrenaline injection calling for IV injection of salbutamol. Furthermore, adrenaline may cause severe hypertension in those receiving beta-blockers.
Patients on tricyclic antidepressants are considerably more susceptible to arrhythmias, calling for a much-reduced dose of adrenaline
Adverse Effects
Side effects of Epinephrine (Adrenaline, Parenteral) :
Tachycardia, hypertension, tremor, anxiety, cold extremities, sweating, nausea, vomiting, weakness, hyperglycaemia, dizziness have all been reported; Headache common
In overdosage arrhythmias, cerebral haemorrhage, and pulmonary oedema.