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Disclaimer to the On-line Edition
This Manual has been designed for use in the NICU at London Health Sciences Centre (LHSC), London, Ontario, Canada, and represents clinical practice at this institution. The information contained within the Manual may not be applicable to other centres. If users of this Manual are not familiar with a drug, it is recommended that the official monograph be consulted before it is prescribed and administered. Any user of this information is advised that the contributors, Editor and LHSC are not responsible for any errors or omissions, and / or any consequences arising from the use of the information in this Manual.

L-EPINEPHRINE
(Epinephrine, Adrenaline)

Indication

  • restore cardiac rhythm in cardiac arrest, improve myocardial status and facilitate defibrillation

Pharmacology

  • epinephrine is the final product in catecholamine biosynthesis
  • at low doses, epinephrine acts on the beta2 receptors to produce vasodilation in skeletal muscle (as well as relaxation of bronchial smooth muscle)
  • stimulates both alpha1 and beta2 and beta2 adrenergic receptors and on the beta1 adrenergic receptors in the heart to produce a positive chronotropic and inotropic effect; systolic blood pressure may be slightly increased as a result of the increased cardiac output; diastolic blood pressure may be decreased because of vasodilation
  • at higher doses, epinephrine acts on alpha1 receptors in peripheral blood vessels to produce vasoconstriction and result in an increase in both systolic and diastolic blood pressure

Side Effects

  • vomiting, respiratory distress, hypertension, tachycardia, bronchial and pulmonary edema, arrhythmias
  • repeated injections may cause tissue necrosis as a result of vasoconstriction at the injection site

Precautions

  • over dose can be fatal; check type of solution prescribed, concentration, dosage and route
  • protect epinephrine from light
  • NEVER GIVE IM in neonates
  • monitor BP and heart rate continuously
  • overdose: treatment is mainly supportive; the pressor effects may be counteracted by an alpha adrenergic blocking drug such as phentolamine; however, prolonged hypotension may follow, which may require a pressor agent such as norepinephrine; arrhythmias, if they occur, may be treated with a beta adrenergic blocking drug, such as propranolol; kidney failure, metabolic acidosis, and cold, white skin may occur
  • local: blanching, tissue ischemia or necrosis may occur with extravasation. Use phentolamine (see phentolamine monograph) if this occurs.

Dose

IV Push

  • Do NOT administer a high dose intravenously.
  • 0.1 to 0.3 mL/kg of a 1:10,000 solution, direct IV push over 1 to 3 minutes, given by a physician
  • 0.3 to 1 mL/kg of a 1:10,000 solution given via ENDOTRACHEAL TUBE, given by a physician
  • may be repeated every 5 minutes

Endotracheal Tube

  • if administered via Endotracheal Tube and volume is <0.3 mL, dilute solution 1:1 with normal saline to aid delivery of the drug
  • our clinical experience during resuscitation in the case room is that there is almost an immediate effect when epinephrine is given via the Endotracheal tube

Intracardiac

  • may also be given intracardiac (0.1 mL/kg of a 1:10,000 (0.1 mg/mL) solution) by a physician

Continuous IV Infusion

  • 0.05 to 1 mcg/kg/min
  • Pharmacy to supply all infusions, as standard concentrations:
    • Patients 1kg or less:  8mcg/mL solution supplied as 400mcg or 0.4mg in total volume of 50mL of IV fluid specified
    • patients over 1kg but less than 3kg:  16mcg/mL solution supplied as 800mcg or 0.8mg in total volume of 50mL of IV fluid specified
    • patients over 3kg: 32mcg/mL solution supplied as 1600mcg or 1.6mg in total volume of 50mL of IV fluid specified
For the indication "to improve upper airway obstruction", L-epinephrine may be used in place of Racemic Epinephrine Inhalation Solution (a mixture of D- and L- isomers of epinephrine). The route of administration is via nebulizer. Pharmacy to send as patient specific medication; this product no longer in Pyxis.

0.25 mL Racemic epinephrine (2.25%) = 2.5 mL L-epinephrine (1 : 1,000)
0.5   mL Racemic epinephrine (2.25%) = 5    mL L-epinephrine (1 : 1,000)

 

Supplied

  • L-epinephrine : 1:10,000 (0.1 mg/mL), 10 mL vial
  • Supplied by Pharmacy as patient specific syringes of standard concentrations (see above)
  • protect vial and ampoules from light: DO NOT use if the solution is coloured (brown) or contains a precipitate; the infusion solution, dextrose or sodium chloride, is stable for 24 hours and does not have to be protected from light

References

  1. McEvoy G K (ed): AHFS Drug Information, American Society of Hospital Pharmacists, 1991.
  2. Roberts, RJ: Drug Therapy in Infants, W.B. Saunders, Toronto, 1984.
  3. Fanaroff AA and Martin RJ (eds): Neonatal-Perinatal Medicine, Mosley, Toronto, 1992.
  4. Gomella TL (Ed): Neonatology - Management, Procedures, On-Call Problems, Diseases, Drugs, 1992, Appleton and Lange, Norwalk, Connecticut.
  5. Bhatt DR, Furman GI, Reber DJ et al: Neonatal Drug Formulary, 1990-1991, 2nd Edition, Fontana, California 92334.
  6. Taketomo CK, Hodding JH and Kraus DM: Pediatric Dosage Handbook, Lexi-Comp Inc., Cleveland, 1992.
  7. Fraser BD : Nebulized levo-epinephrine as an alternative to racemic epinephrine in pediatrics, The Canadian Journal of Hospital Pharmacy 1995; 48: 303-304.
  8. Waisman Y, Klein BL, Boenning DA et al : Prospective double-blind study comparing L-epinephrine and racemic epinephrine in the treatment of laryngotracheitis, Pediatrics 1992; 89 : 302-306.
  9. Remington S and Meakin G : Nebolised adrenaline 1:1,000 in the treatment of croup, Anaesthesia 1986; 41 : 923-926.
  10. Newton DW, Fung EYY, Williams DA : Stability of five catecholamines and terbutaline sulfate in 5% dextrose injection in the absence and presence of aminophylline. American Journal of Hospital Pharmacy 1981;38:1314-1319.
  11. Summary of Major Changes to the 2005 AAP / AHA Emergency Cardiovaxcular care Guidelines for neonatal resuscitation. Vol 15 No 2. fall / Winter 2005.

Updated: December 9, 2005




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