Racemic Epinephrine

Aka: Racemic Epinephrine, Nebulized racemic epinephrine

1. Indications
   1. Moderate to Severe Croup
   2. Respiratory Syncytial Virus (Bronchiolitis)
2. Mechanism
   1. Alpha-adrenergic effect
   2. Mucosal Vasoconstriction decreases subglottic edema
   3. Rapid response in croup (within 10-30 minutes)
      1. Consider Croup Differential Diagnosis if no response
   4. Effect dissipates in 2 hours (some effects may persist up to 4 hours)
3. Pharmacokinetics
   1. Effect onset within 10-30 minutes
   2. Effects last 90 to 120 minutes (with some effects lasting up to 4 hours)
4. Precautions
   1. Avoid too frequent use due to tachyphylaxis
   2. Observe 2-3 hours after Racemic Epinephrine
      1. Patient may go home safely if no worsening in 2-3 hours
         1. Most croup decompensations will occur 1 to 1.5 hours after nebulized Epinephrine
      2. Typically admit patient if requires repeat Epinephrine nebs
         1. See Croup protocol which allows discharge after 2 Epinephrine nebs and adequate observation without decompensation
5. Dose
   1. See Croup
   2. Nebulizer mix
      1. Normal Saline 2.0 to 3.5 ml
      2. Racemic Epinephrine (2.25%)
         1. Dose: 0.05 ml/kg (maximum 0.5 ml in children)
         2. Child under 6 months: 0.25 ml
         3. Child: 0.5 ml
         4. Adolescent: 0.75 ml
   3. Alternative option
      1. L-Epinephrine 0.5 ml/kg (maximum 5 ml) of 1:1,000 via nebulizer
         1. Similar efficacy to Racemic Epinephrine and more widely available
   4. Frequency of dosing
      1. Nebulized Epinephrine may be repeated in 30 minutes
      2. Monitor Heart Rate closely with repeat dosing
6. Efficacy: Bronchiolitis
   1. Significantly more effective than Beta-agonist
   2. Reduced hospital admissions significantly
   3. Reduced time spent in emergency room significantly
   4. References
      1. Menon (1995) J Pediatr 126:1004-7 [PubMed]