Epinephrine

See critical care quick reference for drug doses by weight.

General

• Type: Vasopressors
• Dosage Forms:
• Concentration
  • Amount of solution in mL used to dilute 1,000mg of epinephrine
  • eg 1:10,000 = 1,000mg/10,000mL = 0.1mg/mL
• Common Trade Names: Adrenaline, EpiPen (IM autoinjector)

Adult Dosing

Anaphylaxis

0.3-0.5mg of 1:1,000 IM

• Consider glucagon 1-5mg IV if patient on beta-blockers and not responding to epi

Anaphylactic shock

0.1mg of 1:10,000 slow IV during 5 min, can start infusion of 1-4 mcg/min

Cardiac Arrest

1mg of 1:10,000 IVP (10cc's total or 1 "amp")

Quick Epi Drip

• Take your code-cart epinephrine (it does not matter if It is 1:1,000 or 1:10,000) and inject 1mg into a liter bag of NS. Final concentration is 1mcg/ml. Run at 1cc/min and titrate to effect.

Pressor drip

• 0.1-1 mcg/kg/min

Pediatric Dosing

See critical care quick reference for drug doses by weight.

Pulseless Arrest

• 0.01 mg/kg (1:10,000 solution) IV/IO q3-5 min
• Max: 1mg/dose

Anaphylaxis

• 0.01 mg/kg (1:1,000 solution) SC/IM x 1
  • Max: 0.3 mg/dose in pre-pubertal patients; 0.5 mg/dose in teenage patients
  • May repeat dose q5-15 min x 2

Severe Asthma

• 0.01 mg/kg (1:1,000 solution) SC/IM x 1
  • Max: 0.3 mg/dose in pre-pubertal patients; 0.5 mg/dose in teenage patients
  • May repeat dose q5-15 min x 2

Pressor drip

• 0.1-1 mcg/kg/min

Special Populations

• Pregnancy Rating: C
• Lactation risk: Infant risk cannot be ruled out
• Renal Dosing
  • Adult
  • Pediatric
• Hepatic Dosing
  • Adult
  • Pediatric

Contraindications

• Allergy to class/drug

Adverse Reactions

• Tachyarrhythmias
• Myocardial ischemia
• Increased serum lactate
• Splanchnic ischemia
• Digital EpiPen injection

Pharmacology

• Onset of action: 1-2 minutes (IV), 8-10 minutes (IM)
• Half-life: < 5 minutes (IV), 45 minutes (IM)
• Metabolism: Hepatic
• Excretion: Renal
• Mechanism of action: potent α and β agonist that increases cardiac output and peripheral vascular resistance

Mechanism of Action

Primary Receptor

• β₁
• α₁
• β₂

Relative Effects

• ↑↑↑HR
• ↑↑↑SV
• ↑↑↑SVR
• Bronchodilation (β₂)

Dose-dependent effects

• 1-10 mcg/min - increase HR and SV ("inotropic" epinephrine)
• 10-20 mcg/min - increase SVR

Notes

• ↑lactate occurs primarily from ↑glycolysis/glycogenolysis within skeletal muscles not tissue hypoperfusion
• Use with caution in patients with CAD
  • However clinical trials have not demonstrated worsened outcomes

Indications

• Epi versus norepi in patients with shock found that elevated levels of lactic acidosis or tachycardia in 13% of epi patients causes
• Second-line agent in sepsis that should be considered after shock is refractory to other vasopressors 2/2 increased number of adverse events that include tachydysrhythmias and lactate production

See Also

• Digital EpiPen Injection
• Critical care quick reference

References

http://www.atsjournals.org/doi/abs/10.1164/rccm.201006-0972CI?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed#readcube-epdf