Brand Name
Adrenalin, Adrenalin Chloride Solution, Ana-Guard, Bronkaid Mist, Bronkaid
Mistometer (CAN), EpiPen (CAN), EpiPen Auto-Injector, EpiPen Jr. (CAN), EpiPen
Jr. Auto-Injector, Primatene Mist
epinephrine bitartrate
Asthmahaler Mist, Bronkaid Suspension Mist
racepinephrine
AsthmaNefrin, MicroNefrin, Nephron, Vaponefrin
Class and Category
Chemical class: Catecholamine
Therapeutic class: Antianaphylactic, bronchodilator,
cardiac stimulant, vasopressor
Pregnancy category: C
Indications and Dosages
To treat bronchospasm
INHALED SOLUTION (EPINEPRHINE)
Adults and children age 4 and over. 1 to 3
inhalations (10 drops) by hand-bulb nebulizer no more than every 3 hr.
INHALED SOLUTION (RACEPINEPHRINE)
Adults and children age 4 and over. 3
inhalations of 0.5 ml (10 drops) by handbulb nebulizer, or 0.2 to 0.5 ml
(4 to 10 drops) of diluted solution given over 15 min by jet
nebulizer; repeated after 3 to 4 hr, if needed.
ORAL INHALED AEROSOL (EPINEPHRINE BITARTRATE)
Adults and children age 4 and over. 1
inhalation (160 mcg) repeated after 1 min, if needed; then repeated
after at least 3 hr.
ORAL INHALER (EPINEPHRINE)
Adults and children age 4 and over. 1
inhalation (200 to 275 mcg) repeated after at least 1 min, if needed;
then repeated after at least 3 hr.
To treat croup
INHALED SOLUTION (RACEPINEPHRINE)
Children. 0.05 ml/kg diluted to 3 ml in normal saline
solution and given over 15 min every 2 hr, as needed. Maximum: 0.5
ml/dose.
To treat anaphylaxis
I.V. INFUSION
Adults and adolescents. 100 to 250 mcg given slowly.
I.M. OR SUBCUTANEOUS INJECTION
Adults and adolescents. 100 to 500 mcg repeated every 10
to 15 min, as needed. Maximum: 1 mg/dose; three doses.
Children. 10 mcg/kg repeated every 15 min for three
doses. Maximum: 300 mcg/dose.
To treat severe anaphylactic shock
I.V. INFUSION
Adults. 1 mcg/min titrated to 2 to 10 mcg/ min for desired hemodynamic
response.
To treat cardiac arrest
I.V. INJECTION
Adults. 0.5 to 1 mg every 3 to 5 min during resuscitation.
Children. 10 mcg/kg followed by 100 mcg/kg every 3 to 5
min, if needed. If two doses produce no response, subsequent doses are increased
to 200 mcg/kg every 5 min.
Neonates. 10 to 30 mcg/kg every 3 to 5 min.
Mechanism of Action
Acts on alpha and beta receptors. This nonselective adrenergic
agonist stimulates:
• alpha1 receptors, which constricts arteries and may decrease
bronchial secretions
• presynaptic alpha2 receptors, which inhibits norepinephrine
release by way of negative
feedback
•
postsynaptic alpha2 receptors, which constricts arteries
•
beta1 receptors, which induces positive chronotropic and inotropic responses
•
beta2 receptors, which dilates arteries, relaxes bronchial smooth muscles,
increases glycogenolysis, and prevents mast cells from secreting histamine and
other substances, thus reversing bronchoconstriction and edema.
Route
Onset Peak Duration
I.V.,
I.M. Rapid Unknown 1–2 min
SubQ
5–10 min In 20 min Short
Oral
1–5 min In 5–15 Up to3 hr
Incompatibilities
Don’t
mix epinephrine with alkalies or oxidizing agents, including bromine, chlorine,
chromates, iodine, metal salts (as from iron), nitrites, oxygen, and
permanganates, because these substances can destroy epinephrine.
Contraindications
Cerebral
arteriosclerosis, coronary insufficiency, counteraction of phenothiazineinduced
hypotension, dilated cardiomyopathy, general anesthesia with halogenated hydrocarbons
or cyclopropane, hypersensitivity to epinephrine or its components, labor, angle-closure
glaucoma, organic brain damage, shock (nonanaphylactic)
Interactions
DRUGS
alpha-adrenergic
blockers, drugs with alphaadrenergic action, rapid-acting vasodilators: Blockage of
epinephrine’s alpha-adrenergic effect, possibly causing severe hypotension
and tachycardia
amyl
nitrite, nitrates: Decreased
antianginal effects
antihypertensives,
diuretics used to treat hypertension: Decreased antihypertensive effects
beta
blockers: Mutual
inhibition of therapeutic effects, possibly severe hypertension and cerebral
hemorrhage
chlorpheniramine,
diphenhydramine, levothyroxine, MAO inhibitors, tricyclic antidepressants, tripelennamine:
Possibly
increased effects of epinepherine
digoxin,
diuretics, quinidine: Increased
risk of arrhythmias
dihydroergotamine,
ergoloid mesylates, ergonovine, ergotamine, methylergonovine, methysergide,
oxytocin: Increased
risk of vasoconstriction, causing gangrene, peripheral vascular
ischemia, or severe hypertension ergot alkaloids: Possibly reversed
pressor effects of epinephrine
hydrocarbon
inhalation anesthetics: Increased risk of severe atrial and ventricular arrhythmias
insulin,
oral antidiabetic drugs: Decreased effects of these drugs
MAO
inhibitors: Possibly
increased vasopressor effect of epinephrine and hypertensive crisis
maprotiline,
tricyclic antidepressants: Potentiated cardiovascular effects of epinephrine, possibly
causing arrhythmias, hyperpyrexia, severe hypertension, or tachycardia
sympathomimetics:
Additive
CNS stimulation, increased cardiovascular effects of either drug
thyroid
hormones: Increased
effects of either drug
xanthines:
CNS
stimulation and toxic effects
Adverse
Reactions
CNS:
Anxiety,
apprehensiveness, chills, fever, dizziness, drowsiness, hallucinations, headache,
insomnia, light-headedness, nervousness, restlessness, seizures, stroke, temporary
worsening of Parkinson’s disease, tremor, weakness
CV:
Arrhythmias,
including ventricular fibrillation; chest discomfort or pain; fast, irregular,
or slow heartbeat; palpitations; severe hypertension; tachycardia
EENT:
Blurred
vision, dry mouth or throat, miosis
ENDO:
Hyperglycemia
in diabetics
GI:
Anorexia,
heartburn, nausea, vomiting
GU:
Dysuria
MS:
Muscle
twitching, severe muscle spasms
RESP:
Dyspnea
SKIN:
Cold
skin, diaphoresis, ecchymosis, flushed or red face or skin, pallor, tissue necrosis
Other:
Hyperkalemia;
hypokalemia; injection site coldness, hypoaesthesia,
pain, pallor, and stinging
Nursing Considerations
• Use epinephrine with extreme caution in patients with angina, arrhythmias,
asthma, degenerative heart disease, or emphysema. Epinephrine’s inotropic
effect equals that of dopamine and dobutamine; its chronotropic effect exceeds
that of both.
• Use drug cautiously in elderly patients and those with
cardiovascular disease (other than listed above), diabetes mellitus,
hypertension, hyperthyroidism, prostatic hypertrophy, and psychoneurologic
disorders.
• Be aware that some preparations contain sulfites, which may
cause allergic-type reactions. However, the presence of sulfites in epinephrine
should not deter its use in a patient with anaphylaxis, even if patient is
sensitive to sulfites. Monitor patient closely for adverse effects.
• Dilute the 1:1,000 (1-mg/ml) solution of parenteral epinephrine
before I.V. use.
• Shake suspension thoroughly before withdrawing dose; refrigerate
it between uses.
• Inspect epinephrine solution or suspension before use. If it’s
pink or brown, air has entered a multidose vial. If it’s discolored or contains
particles, discard it. Also discard unused portions of parenteral epinephrine.
• For injection, rotate sites because repeated injections in the
same site may cause vasoconstriction and localized necrosis.
• Be aware that drug shouldn’t be given by intra-arterial
injection because marked vasoconstriction may cause gangrene.
• Avoid giving injection into buttocks because drug may be less
effective when given there, especially for treating anaphylaxis.
•Monitor patient for potassium imbalances. Initially, hyperkalemia
occurs when hepatocytes release potassium. Hypokalemia may quickly follow as
skeletal muscles take up potassium.
• To minimize insomnia, give last dose a few hours before bedtime.
WARNING To treat cardiac arrest, at least twice the
peripheral I.V. dose of epinephrine may be given by endotracheal instillation. Two
dilutions are needed for this regimen; use great caution to avoid making medication
errors.
PATIENT TEACHING
•Warn patient not to exceed recommended dosage or to shorten
interval because of the risk of adverse reactions and tolerance.
• Advise patient to notify prescriber if symptoms don’t improve or
if they improve but then worsen.
• Instruct patient to take the day’s last dose a few hours before
bedtime to avoid insomnia.
• Caution patient not to use inhalation solution that is pink or
brown or that contains particles.
• Teach patient how to use oral inhaler or inhalation solution, as
needed.
• If patient also uses an oral corticosteroid inhaler, instruct
him to use epinephrine inhaler first, wait 5 minutes, and then use corticosteroid
inhaler to increase effectiveness.
• Teach patient and family how to administer epinephrine
subcutaneously in an emergency. Tell them to inject drug into anterolateral
aspect of the thigh, through the clothing if necessary. Explain that solution
is light sensitive and should be stored in the carrying case and at room temperature.
Tell them not to refrigerate drug and to replace solution if it discolors.
• Caution patient to avoid accidental injecting drug into his
fingers, hands, toes, or feet because epinephrine is a strong vasoconstrictor and
could cause loss of blood flow to the area, resulting in gangrene. If accidental
injection occurs in any of these areas, instruct patient to go immediately to
nearest emergency room.
• Advise patient to notify prescriber immediately if he has
blurred vision, chest pain, trouble breathing, a fast or irregular heartbeat, or
increased sweating.
• Inform patient with diabetes that epinephrine may cause
hyperglycemia. Inform patient with Parkinson’s disease that symptoms my
temporarily worsen but this should not deter use of drug.
