EPINEPHRINE

EPINEPHRINE
(ep-i-ne'frin)
Epinephrine Pediatric, EpiPen Auto-Injector, Primatene Mist Suspension
EPINEPHRINE BITARTRATE
AsthmaHaler, Bronkaid Mist Suspension, Bronitin Mist Suspension, Epitrate, Primatene Mist Suspension
EPINEPHRINE HYDROCHLORIDE
Adrenalin Chloride, Bronkaid Mistometer, Dysne-Inhal, SusPhrine 
EPINEPHRINE, RACEMIC
Vaponefrin 
Classifications: alpha- and beta-adrenergic agonist; cardiac stimulant; vasopressor;
Therapeutic: anti-anaphylactic
; cardiac stimulant; vasopressor
Pregnancy Category: C

Availability

1:100, 1:1000, 2.25% solution for inhalation; 0.35 mg, 0.2 mg spray; 1:1000, 1:2000, 1:10,000, 1:100,000 injection; 1:200 suspension; 0.1%, 0.5%, 1%, 2% ophthalmic solution; 0.1% nasal solution

Action

Naturally occurring catecholamine obtained from animal adrenal glands; it is also prepared synthetically. Acts directly on both alpha and beta receptors; the most potent activator of alpha receptors. Strengthens myocardial contraction; increases systolic but may decrease diastolic blood pressure; increases cardiac rate and cardiac output. Constricts bronchial arterioles and inhibits histamine release, thus reducing congestion and edema and increasing tidal volume and vital capacity. Relaxes uterine smooth musculature and inhibits uterine contractions.

Therapeutic Effect

Imitates all actions of sympathetic nervous system except those on arteries of the face and sweat glands.

Uses

Temporary relief of bronchospasm, acute asthmatic attack, mucosal congestion, hypersensitivity and anaphylactic reactions, syncope due to heart block or carotid sinus hypersensitivity, and to restore cardiac rhythm in cardiac arrest. Ophthalmic preparation is used in management of simple (open-angle) glaucoma, generally as an adjunct to topical miotics and oral carbonic anhydrase inhibitors; also used as ophthalmic decongestant. Relaxes myometrium and inhibits uterine contractions; prolongs action and delays systemic absorption of local and intraspinal anesthetics. Used topically to control superficial bleeding.

Contraindications

Hypersensitivity to sympathomimetic amines; narrow-angle glaucoma; hemorrhagic, traumatic, or cardiogenic shock; cardiac dilatation, cerebral arteriosclerosis, coronary insufficiency, arrhythmias, organic heart or brain disease; during second stage of labor; for local anesthesia of fingers, toes, ears, nose, genitalia; pregnancy (category C).

Cautious Use

Older adults or debilitated patients; prostatic hypertrophy; hypertension; diabetes mellitus; hyperthyroidism; Parkinson's disease; tuberculosis; psychoneurosis; in patients with long-standing bronchial asthma and emphysema with degenerative heart disease; lactation.

Route & Dosage

Anaphylaxis
Adult: SC 0.1–0.5 mL of 1:1000 q10–15min prn IV 0.1–0.25 mL of 1:1000 q5–15min
Child: SC 0.01 mL/kg of, 1:1000 q10–15min prn IV 0.01 mL/kg of 1:1000 q10–15min
Neonate: IV Intratracheal 0.01–0.05 mg/kg q3–5min prn

Cardiac Arrest
Adult: IV 1 mg q3–5min as needed Intracardiac 0.1–1 mg
Child: IV 0.01 mg/kg q3–5min as needed (max: 1 mg) Intracardiac 0.05–0.1 mg/kg

Asthma
Adult: SC 0.1–0.5 mL of 1:1000 q20min–4h Inhalation 1 inhalation q4h prn
Child: SC 0.01 mL/kg of 1:1000 q20min–4h Inhalation 1 inhalation q4h prn

Glaucoma
Adult/Child: Instillation 1–2 drops 0.25–2% solution 1/d or b.i.d.

Ocular Mydriasis

See Appendix A-1


Nasal Hemostasis
Adult/Child: Instillation 1–2 drops 0.1% ophthalmic or 0.1% nasal solution

Topical Hemostatic
Adult/Child: Topical 1:50,000–1:1000 applied topically or 1:500,000–1:50,000 mixed with a local anesthetic

Administration

Inhalation
  • Have patient in an upright position when aerosol preparation is used. The reclining position can result in overdosage by producing large droplets instead of fine spray.
  • Instruct patient to rinse mouth and throat with water immediately after inhalation to avoid swallowing residual drug (may cause epigastric pain and systemic effects from the propellant in the aerosol preparation) and to prevent dryness of oropharyngeal membranes.
  • Do not give isoproterenol concurrently with epinephrine. Allow 4-h interval to elapse before a change is made from one drug to the other.
Instillation
  • Instill nose drops with head in lateral, head-low position to prevent entry of drug into throat.
  • Instruct patient to rinse nose dropper or spray tip with hot water after each use to prevent contamination of solution with nasal secretions.
Ophthalmic
  • Remove soft contact lenses before instilling eye drops.
  • Instruct patient to apply gentle finger pressure against nasolacrimal duct immediately after drug is instilled for at least 1 or 2 min following instillation to prevent excessive systemic absorption.
  • When separate solutions of epinephrine and a topical miotic are used, the miotic should be instilled 2–10 min prior to epinephrine because of the conjunctival sac's limited capacity.
Subcutaneous
  • Use tuberculin syringe to ensure greater accuracy in measurement of parenteral doses.
  • Protect epinephrine injection from exposure to light at all times. Do not remove ampule or vial from carton until ready to use.
  • Shake vial or ampule thoroughly to disperse particles before withdrawing epinephrine suspension into syringe; then inject promptly.
  • Aspirate carefully before injecting epinephrine. Inadvertent IV injection of usual SC doses can result in sudden hypertension and possibly cerebral hemorrhage.
  • Rotate injection sites and observe for signs of blanching. Vascular constriction from repeated injections may cause tissue necrosis.
Intravenous
  • Note: Verify correct rate of IV injection to neonates, infants, children with physician.
  • Note: 1:1000 solution contains 1 mg/1 mL. 1:10,000 solution contains 0.1 mg/1 mL.

PREPARE: Direct: Dilute each 1 mg of 1:1000 solution with 10 mL of NS to yield 1:10,000 solution.  IV Infusion: Further dilute in 250–500 mL of D5W.  

ADMINISTER: Direct: Give each 1 mg over 1 min or longer; may give more rapidly in cardiac arrest.  IV Infusion: 1–10 mcg/min titrated according to patient's condition.  

INCOMPATIBILITIES Solution/additive: Aminophylline, cephapirin, hyaluronidase, mephentermine, sodium bicarbonate, warfarin. Y-site: Ampicillin, thiopental, sodium bicarbonate.

Adverse Effects (≥1%)

Special Senses: Nasal burning or stinging, dryness of nasal mucosa, sneezing, rebound congestion. Transient stinging or burning of eyes, lacrimation, browache, headache, rebound conjunctival hyperemia, allergy, iritis; with prolonged use: melanin-like deposits on lids, conjunctiva, and cornea; corneal edema; loss of lashes (reversible); maculopathy with central scotoma in aphakic patients (reversible). Body as a Whole: Nervousness, restlessness, sleeplessness, fear, anxiety, tremors, severe headache, cerebrovascular accident, weakness, dizziness, syncope, pallor, sweating, dyspnea. GI: Nausea, vomiting. CV: Precordial pain, palpitations, hypertension, MI, tachyarrhythmias including ventricular fibrillation. Respiratory: Bronchial and pulmonary edema. Urogenital: Urinary retention. Skin: Tissue necrosis with repeated injections. Metabolic: Metabolic acidoses, elevated serum lactic acid, transient elevations of blood glucose. CNS: Altered state of perception and thought, psychosis.

Interactions

Drug: May increase hypotension in circulatory collapse or hypotension caused by phenothiazines, oxytocin, entacapone. Additive toxicities with other sympathomimetics (albuterol, dobutamine, dopamine, isoproterenol, metaproterenol, norepinephrine, phenylephrine, phenylpropanolamine, pseudoephedrine, ritodrine, salmeterol, terbutaline), mao inhibitors, tricyclic antidepressants. alpha- and beta-adrenergic blocking agents (e.g., ergotamine, propranolol) antagonize effects of epinephrine. general anesthetics increase cardiac irritability.

Pharmacokinetics

Absorption: Inactivated in GI tract. Onset: 3–5 min, 1 h on conjunctiva. Peak: 20 min, 4–8 h on conjunctiva. Duration: 12–24 h topically. Distribution: Widely distributed; does not cross blood–brain barrier; crosses placenta. Metabolism: Metabolized in tissue and liver by monoamine oxidase (MAO) and catecholamine-methyltransferase (COMT). Elimination: Small amount excreted unchanged in urine; excreted in breast milk.

Nursing Implications

Assessment & Drug Effects

  • Monitor BP, pulse, respirations, and urinary output and observe patient closely following IV administration. Epinephrine may widen pulse pressure. If disturbances in cardiac rhythm occur, withhold epinephrine and notify physician immediately.
  • Keep physician informed of any changes in intake-output ratio.
  • Use cardiac monitor with patients receiving epinephrine IV. Have full crash cart immediately available.
  • Check BP repeatedly when epinephrine is administered IV during first 5 min, then q3–5min until stabilized.
  • Advise patient to report to physician if symptoms are not relieved in 20 min or if they become worse following inhalation.
  • Advise patient to report bronchial irritation, nervousness, or sleeplessness. Dosage should be reduced.
  • Monitor blood glucose & HbA1C for loss of glycemic control if diabetic.

Patient & Family Education

  • Be aware intranasal application may sting slightly.
  • Administer ophthalmic drug at bedtime or following prescribed miotic to minimize mydriasis, with blurred vision and sensitivity to light (possible in some patients being treated for glaucoma).
  • Transitory stinging may follow initial ophthalmic administration and that headache and browache occur frequently at first but usually subside with continued use. Notify physician if symptoms persist.
  • Discontinue epinephrine eye drops and consult a physician if signs of hypersensitivity develop (edema of lids, itching, discharge, crusting eyelids).
  • Learn how to administer epinephrine subcutaneously. Keep medication and equipment available for home emergency. Confer with physician.
  • Note: Inhalation epinephrine reduces bronchial secretions and thus may make mucous plugs more difficult to dislodge.
  • Report tolerance to physician; may occur with repeated or prolonged use. Continued use of epinephrine in the presence of tolerance can be dangerous.
  • Take medication only as prescribed and immediately notify physician of onset of systemic effects of epinephrine.
  • Discard discolored or precipitated solutions.

Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug

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