Pharm
Epinephrine
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Epinephrine
, Adrenaline, Dirty Epinephrine Drip, Epinephrine Push Dose Pressor
Definition
Natural
Catecholamine
with Alpha and beta activity
History
Medical case report in 1923 on intracardiac Adrenaline
Shown to reverse "Acute heart paralysis"
Pathophysiology
Alpha Adrenergic Agonist Effects
Most important for
Cardiac Arrest
Vasocon
striction
Increases Systemic Vascular Resistance
Increases Systolic and Diastolic
Blood Pressure
Increases Vital Organ Perfusion
Increases Myocardial perfusion
Increases Cerebral perfusion
Decreases Non-Vital Organ Perfusion
Decreases splanchnic and intestinal perfusion
Decreases renal perfusion
Decreases skin perfusion
Beta Adrenergic Agonist effects (Under 0.3 ug/kg/min)
Increases myocardial contractility
Increases
Heart Rate
Relaxes
Bronchi
al smooth muscle (bronchodilation)
Epinephrine has a short half-life: ~2 minutes
Indications
Initial
Resuscitation
Management (bolus)
Cardiac Arrest
Vasopressin
may be used instead in some protocols
Symptomatic Bradycardia
unresponsive to
Oxygenation
Ventilation
Hypotension
refractory to volume replacement
Post-
Resuscitation
Stabilization (Infusion)
Poor systemic perfusion or
Hypotension
despite
Intravascular volume replacement AND
Stable rhythm
Significant
Bradycardia
Dosing
Newborn (refractory and persistant
Bradycardia
)
Epinephrine (1:10,000) 0.1 to 0.3 ml/kg by IV or ET
Do not use the 1:1000 concentration in newborns
Dosing
Pediatric
Symptomatic Bradycardia
(with a pulse)
Dose: 0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 Epi)
Pulse
less
Cardiac Arrest
Initial regular dose Epinephrine
Dose: 0.01 mg/kg IV/IO (0.1 ml/kg of 1:10,000 Epi)
Subsequent High Dose Epinephrine (if no effect above)
Dose: 0.1 mg/kg IV/IO (0.1 ml/kg of 1:1000 Epi)
Maximum dose: 0.2 mg/kg
Repeat dose every 3-5 minutes
Endotracheal Administration
Adults and children: 0.1 mg/kg (0.1 ml/kg of 1:1000)
Newborn: 0.1 mg/kg (1 ml/kg of 1:10,000)
Dosing
Pediatric Infusion (Same as
Isoproterenol
preparation)
Preparation
Draw up "x" mg of Epinephrine
Where "x" = 0.6 x WeightKg
Add enough D5W or NS to Epinephrine for 100 ml total
At this dilution
Infusion rate of 1 ml/h provides 0.1 ug/kg/h
Start Dose: 20 ml/hour until
Tachycardia
Indicates drug has entered circulation
Titrate Dose
Decrease to desired rate (0.1 - 1.0 ug/kg/min)
Adjust infusion rate every 5 min to desired effect
Dosing
Adult
Pulse
less Arrest
Rhythms
Asystole
Pulseless Electrical Activity
Ventricular Fibrillation
Initial
IV: 1 mg (10 ml of 1:10,000 Epi) IV push
Endotracheal: 2.5 ml of 1:1000 Epi in 10 ml NS
Repeat every 3-5 minutes
Consider increasing dose to 3 or 5 mg (0.1 mg/kg)
Dosing
Anaphylaxis
"Dirty" Epinephrine drip ("dirty epi drip")
Indicated if repeat intramuscular Epinephrine dosing is required for
Anaphylaxis
Ordered at the time of second IM Epinephrine dose
Preparation: Epinephrine 1 mcg/ml solution
Draw up 1 mg of Epinephrine (1 ml of 1:1000 or 10 ml of 1:10000)
Inject 1 mg Epinephrine into 1 Liter bag of
Normal Saline
(now 1 mcg/ml Epinephrine)
Given 1 cc/20 drops AND 1 mcg/ml Epinephrine
Goal rate: 6 mcg/min
Equates to 2 drops per second
Infusion: Epinephrine 1 mcg/ml solution
Protocol 1: Hypotensive, unstable patient option 1
Draw into syringe, 10 ml (10 mcg) from 1 mcg/ml Epinephrine solution prepared above
Inject 5 ml (5 mcg) IV (may repeat second 5 ml/5 mcg dose)
Protocol 2: Hypotensive, unstable patient option 2
Open Epinephrine solution IV (flows at 20-50 mcg/min through 18 gauge IV)
Provider stands by the bedside and closely controls infusion
Titrate until patient hemodynamically stable
Decrease the Epinephrine flow as patient becomes hemodynamically stable
Decrease flow towards 1-4 mcg/min
Wean as approach cummulative max IV Epinephrine dose
Max cummulative dose: 100 mcg (3-5 min with open IV)
Equivalent of the initial
Anaphylaxis
guideline
Recommended bolus of 0.1 mg IV push over 5 minutes
Protocol 3: Cautious titration
Start infusion at 1 mcg/min and titrate to effect (typically 1-4 mcg/min)
References
Lin in Herbert (2014) EM Rap 14(1): 7
Dosing
Adult Infusion for
Symptomatic Bradycardia
Preparation
Draw up 1 mg Epinephrine (1 ml of 1:1000)
Add Epinephrine to 500 ml
Normal Saline
or D5W
Start Dose: 1 ug/min
Titrate Dose to desired effect (2-10 ug/min)
Dosing
Adult
Push Dose Pressor
for
Hypotension
refractory to fluid bolus
See
Push Dose Pressor
See
Intravenous Phenylephrine
Preparation
Start with 9 ml of
Normal Saline
in 10 ml syringe
Draw 1 ml of Cardiac Epinephrine (100 mcg/ml or 0.1 mg/ml or 1 to 10:000 dilution) in vial
Final Concentration: Epinephrine 10 mcg/ml
Dose
Epinephrine (10 mcg/ml) 0.5 to 2 ml (5-20 mcg) every 2-5 minutes
Expect onset of action within 1 minute and effect lasting 5-10 minutes
Precautions
Carefully check concentration (1:1000 OR 1:10,000)
Observe for side effects after
Resuscitation
Supraventricular Tachycardia
Ventricular Tachycardia
Severe Hypertension
Extravasation into tissues
may causes local ischemia or necrosis
Can exacerbate
Myocardial Ischemia
Do not mix with alkaline solutions
Efficacy
Cardiac Arrest
See
Guidelines for Emergency Cardiovascular Care
Epinephrine is recommended in most of the ACLS cardiac guidelines 2010 (recommendation 2B)
More recent data since 2010 guidelines may lead to future modified recommendations (research topic only for now)
Epinephrine appears to have no effect on neurologically intact survival despite significantly increasing rate of
ROSC
Jacobs (2011) Resuscitation 82(9): 1128-43 [PubMed]
Nakahara (2013) BMJ 347: f6829 [PubMed]
Early use of Epinephrine in
Cardiac Arrest
may be associated with better outcomes
Nakahara (2012) Acad Emerg Med 19(7):782-92 [PubMed]
Epinephrine has theoretical risks in
Cardiac Arrest
Tachydysrhthythmias
Increased myocardial oxygen demand
Thrombogenesis
References
Swaminathan and Hayes in Herbert (2014) EM:Rap 14(6): 7-8
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