Pronunciation:

(ep i NEF rin)

U.S. Brand Names:

Synonyms:

Generic Available:

Canadian Brand Names:

Use:

Use - Unlabeled/Investigational:

Pregnancy Risk Factor:

Pregnancy Implications:

Lactation:

Contraindications:

Warnings/Precautions:

Adverse Reactions:

Cardiovascular: Tachycardia (parenteral), pounding heartbeat, flushing, hypertension, pallor, chest pain, increased myocardial oxygen consumption, cardiac arrhythmia, sudden death, angina, vasoconstriction

Central nervous system: Nervousness, anxiety, restlessness, headache, dizziness, lightheadedness, insomnia

Gastrointestinal: Nausea, vomiting, xerostomia,dry throat

Genitourinary: Acute urinary retention in patients with bladder outflow obstruction

Neuromuscular & skeletal: Weakness, trembling

Ocular: Precipitation or or exacerbation of narrow-angle glaucoma, transient stinging, burning, eye pain, allergic lid reaction, ocular irritation

Renal: Decreased renal and splanchnic blood flow

Respiratory: Wheezing, dyspnea

Miscellaneous: Diaphoresis (increased)

Overdosage/Toxicology:

Drug Interactions:

Ethanol/Nutrition/Herb Interactions:

Stability:

Epinephrine is sensitive to light and air; protection from light is recommended

Oxidation turns drug pink, then a brown color; solutions should not be used if they are discolored or contain a precipitate

Stability of injection of parenteral admixture at room temperature (25°C) or refrigeration (4°C): 24 hours

Standard diluent: 1 mg/250 mL NS

Compatible with dopamine, dobutamine, diltiazem

Incompatible with aminophylline, sodium bicarbonate or other alkaline solutions

Compatibility:

Y-site administration: Compatible: Atracurium, calcium chloride, calcium gluconate, cisatracurium, diltiazem, dobutamine, dopamine, famotidine, fentanyl, furosemide, heparin, hydrocortisone sodium succinate, hydromorphone, inamrinone, labetalol, levofloxacin, lorazepam, midazolam, milrinone, morphine, nicardipine, nitroglycerin, norepinephrine, pancuronium, phytonadione, potassium chloride, propofol, ranitidine, remifentanil, vecuronium, vitamin B complex with C, warfarin. Incompatible: Ampicillin, thiopental

Compatibility in syringe: Compatible: Diatrizoate meglumine 52%, diatrizoate sodium 8%, diatrizoate sodium 60%, doxapram, heparin, iohexol, iopamidol, iothalamate meglumine 60%, ioxaglate 39.3%, ioxaglate sodium 19.6%, milrinone. Variable (consult detailed reference): Sodium bicarbonate

Compatibility when admixed: Compatible: Amikacin, bupivacaine, cimetidine, dobutamine, fentanyl, floxacillin, furosemide, metaraminol, ranitidine, verapamil. Incompatible: Aminophylline, hyaluronidase, mephentermine, sodium bicarbonate

Mechanism of Action:

Pharmacodynamics/Kinetics:

Onset of action: Bronchodilation: SubQ: ~5-10 minutes; Inhalation: ~1 minute; Conjunctival instillation: IOP declines ~1 hour

Peak effect: Conjunctival instillation: 4-8 hours

Duration: Conjunctival instillation: Ocular effect: 12-24 hours

Distribution: Crosses placenta; enters breast milk

Metabolism: Taken up into the adrenergic neuron and metabolized by monoamine oxidase and catechol-o-methyltransferase; circulating drug hepatically metabolized

Excretion: Urine (as inactive metabolites, metanephrine, and sulfate and hydroxy derivatives of mandelic acid, small amounts as unchanged drug)

Dosage:

Neonates: Cardiac arrest: I.V.: Intratracheal: 0.01-0.03 mg/kg (0.1-0.3 mL/kg of 1:10,000 solution) every 3-5 minutes as needed; dilute intratracheal doses to 1-2 mL with normal saline

Infants and Children:

Bronchodilator: SubQ: 10 mcg/kg (0.01 mL/kg of 1:1000) (single doses not to exceed 0.5 mg) or suspension (1:200): 0.005 mL/kg/dose (0.025 mg/kg/dose) to a maximum of 0.15 mL (0.75 mg for single dose) every 8-12 hours

Bradycardia:

I.V.: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) every 3-5 minutes as needed (maximum: 1 mg/10 mL)

Intratracheal: 0.1 mg/kg (0.1 mL/kg of 1:1000 solution every 3-5 minutes); doses as high as 0.2 mg/kg may be effective

Asystole or pulseless arrest:

I.V. or intraosseous: First dose: 0.01 mg/kg (0.1 mL/kg of a 1:10,000 solution); subsequent doses: 0.1 mg/kg (0.1 mL/kg of a 1:1000 solution); doses as high as 0.2 mg/kg may be effective; repeat every 3-5 minutes

Intratracheal: 0.1 mg/kg (0.1 mL/kg of a 1:1000 solution); doses as high as 0.2 mg/kg may be effective

Hypersensitivity reaction: SubQ: 0.01 mg/kg every 15 minutes for 2 doses then every 4 hours as needed (single doses not to exceed 0.5 mg)

Refractory hypotension (refractory to dopamine/dobutamine): Continuous I.V. infusions of 0.1-1 mcg/kg/minute; titrate dosage to desired effect

Nebulization: 0.25-0.5 mL of 2.25% racemic epinephrine solution diluted in 3 mL normal saline, or L-epinephrine at an equivalent dose; racemic epinephrine 10 mg = 5 mg L-epinephrine; use lower end of dosing range for younger infants

Intranasal: Children 6 years and Adults: Apply locally as drops or spray or with sterile swab

Adults:

Asystole:

I.V.: 1 mg every 3-5 minutes; if this approach fails, higher doses of epinephrine (up to 0.2 mg/kg) may be used, but are not recommended (Class Indeterminate; 2000 ACLS guidelines)

Intratracheal: Administer 2-2.5 times the recommended I.V. dose; dilute in 10 mL NS or distilled water. Note: Absorption is greater with distilled water, but causes more adverse effects on PaO2.

Bronchodilator: I.M., SubQ (1:1000): 0.1-0.5 mg every 10-15 minutes to 4 hours

Hypersensitivity reaction: I.M., SubQ: 0.3-0.5 mg every 15-20 minutes if condition requires; if hypotension is present: 0.1 mg I.V. slowly over 5-10 minutes followed by continuous infusion 1-10 mcg/minute

Symptomatic bradycardia or heart block (not responsive to atropine or pacing): I.V. infusion: 1-10 mcg/minute; titrate to desired effect

Refractory hypotension (refractory to dopamine/dobutamine): Continuous I.V. infusion 1 mcg/minute (range: 1-10 mcg/minute); titrate dosage to desired effect; severe cardiac dysfunction may require doses >10 mcg/minute (up to 0.1 mcg/kg/minute)

Nebulization: Instill 8-15 drops into nebulizer reservoirs; administer 1-3 inhalations 4-6 times/day

Ophthalmic: Instill 1-2 drops in eye(s) once or twice daily; when treating open-angle glaucoma, the concentration and dosage must be adjusted to the response of the patient

Administration:

Epinephrine can be administered SubQ, I.M., I.V., or intracardiac injection

I.M. administration into the buttocks should be avoided

Preparation of adult I.V. infusion: Dilute 1 mg in 250 mL of D5W or NS (4 mcg/mL); administer at an initial rate of 1 mcg/minute and increase to desired effects; at 20 mcg/minute pure alpha effects occur

1 mcg/minute: 15 mL/hour

2 mcg/minute: 30 mL/hour

3 mcg/minute: 45 mL/hour, etc

Intratracheal: Dilute in NS or distilled water. Absorption is greater with distilled water, but causes more adverse effects on PaO2. Pass catheter beyond tip of tracheal tube, stop compressions, spray drug quickly down tube. Follow immediately with several quick insufflations and continue chest compressions.

Extravasation management: Use phentolamine as antidote. Mix 5 mg with 9 mL of NS. Inject a small amount of this dilution into extravasated area. Blanching should reverse immediately. Monitor site. If blanching should recur, additional injections of phentolamine may be needed.

Monitoring Parameters:

Reference Range:

Test Interactions:

Patient Education:

Ophthalmic: Wash hands before instilling. Sit or lie down to instill. Open eye, look at ceiling, and instill prescribed amount of medication. Close eye and roll eye in all directions, and apply gentle pressure to inner corner of eye. Do not let tip of applicator touch eye; do not contaminate tip of applicator (may cause eye infection, eye damage, or vision loss). Temporary stinging or burning may occur. Report persistent pain, burning, vision changes, swelling, itching, or worsening of condition.

Aerosol: Use aerosol or nebulizer as per instructions. Clear as much mucus as possible before use. Rinse mouth following each use. If more than one inhalation is necessary, wait 1 minute between inhalations. May cause restlessness or nervousness; use caution when driving or engaging in hazardous activities until response to medication is known. Report persistent nervousness, restlessness, sleeplessness, palpitations, tachycardia, chest pain, muscle tremors, dizziness, flushing, or if breathing difficulty persists.

Nasal: Instill 1 spray into each nostril 3-4 times a day. Report if symptoms worsen or nasal passages become irritated.

Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.

Anesthesia and Critical Care Concerns/Other Considerations:

Septic Shock: Epinephrine's use may be limited by its effects on renal and gastric blood flow and its propensity to increase lactic acid concentrations.

Cardiac Arrest: Epinephrine can be given by endotracheal route during cardiac resuscitation. High-intravenous dose epinephrine (0.1 mg/kg) has not shown to improve survival or neurological outcomes. May have more postresuscitation complications than survivors who receive standard dose epinephrine. Eight randomized clinical studies (>9000 patients) have found no improvement in survival to hospital discharge or neurological outcomes compared with standard epinephrine.

A prospective, multicenter, double-blind randomized, controlled trial evaluated the efficacy of vasopressin or epinephrine when administered to adult patients who suffered an out-of-hospital cardiac arrest (Wenzel V, 2004). For inclusions, patients presented with ventricular fibrillation, pulseless electrical activity, or asystole. They were excluded if they were successfully defibrillated without the administration of a vasopressor, had a terminal illness or had a DNR order, a lack of intravenous access, hemorrhagic shock, pregnancy, cardiac arrest due to trauma, or were <18 years of age. Eligible patients were randomized to intravenous vasopressin (40 units) or epinephrine (1 mg). Each patient received an injection of the study drug, if spontaneous circulation was not restored in 3 minutes they received a second dose (same amount) of the same study drug. If there was no response, the managing physician had the option of giving epinephrine. Patients with ventricular fibrillation were randomized after the first three attempts at defibrillation failed; all others were randomized immediately. The primary endpoint was survival to hospital admission; the secondary endpoint was survival to hospital discharge. Five hundred and eighty-nine patients were randomized to vasopressin and five hundred and ninety-seven patients were randomized to epinephrine. There was no significant difference in the rate of hospital admission between the vasopressin group and the epinephrine group if they had ventricular fibrillation (46.2% vs 43% respectively, p: 0.48) or pulseless electrical activity (33.7% vs 30.5% respectively, p: 0.65). Patients with asystole responded significantly better to vasopressin; having higher rates of hospital admission (29% vs 20.3% in the epinephrine group, p: 0.02) and hospital discharge (4.7% vs 1.5% in the epinephrine group, p: 0.04). Patients who failed vasopressin therapy and received additional epinephrine had significant improvement in survival to hospital admission (25.7% vs 16.4% in the epinephrine group, p: 0.002) and discharge (6.2% vs 1.7%, p: 0.002). Similar patients who were randomized to epinephrine and failed to respond did not improve with additional epinephrine. Cerebral performance among all patients who survived to discharge was similar in both groups. In this trial, vasopressin was superior to epinephrine in patients with asystole. Vasopressin followed by epinephrine may be more effective than epinephrine alone in refractory out-of-hospital cardiac arrest.

A small in-hospital cardiac arrest study evaluated the efficacy of vasopressin or epinephrine in 200 patients. These investigators did not find any differences between the two treatment groups with regard to survival, discharge, or cerebral performance (Stiell I, 2001).

Cardiovascular Considerations:

Dental Health: Effects on Dental Treatment:

Mental Health: Effects on Mental Status:

Mental Health: Effects on Psychiatric Treatment:

Dosage Forms:

Aerosol for oral inhalation (Primatene® Mist): 0.22 mg/inhalation (15 mL, 22.5 mL) [contains CFCs]

Injection, solution [prefilled auto injector]:

EpiPen®: 0.3 mg/0.3 mL [1:1000] (2 mL) [contains sodium metabisulfite; available as single unit or in double-unit pack with training unit]

EpiPen® Jr: 0.15 mg/0.3 mL [1:2000] (2 mL) [contains sodium metabisulfite; available as single unit or in double-unit pack with training unit]

Injection, solution, as hydrochloride: 0.1 mg/mL [1:10,000] (10 mL); 1 mg/mL [1:1000] (1 mL) [products may contain sodium metabisulfite]

Adrenalin®: 1 mg/mL [1:1000] (1 mL, 30 mL) [contains sodium bisulfite]

Solution for oral inhalation, as hydrochloride: Adrenalin®: 1% [10 mg/mL, 1:100] (7.5 mL) [contains sodium bisulfite]

Solution, ophthalmic, as hydrochloride (Epifrin®): 0.5% (15 mL); 1% (15 mL); 2% (15 mL) [contains benzalkonium chloride and sodium metabisulfite] [DSC]

International Brand Names: