Full Answer
Racemic epinephrine is given via nebulizer and is effective within 30 minutes of administration. However, racemic epinephrine does not alter the disease course, so patients must be monitored closely for a “rebound effect” after the medication wears off. The recommended monitoring time is 2–4 hours after treatment.
The concentration! Racemic epinephrine is typically dispensed in a 2.25% concentration – that’s 22.5 mg/mL!!! The package instructions usually state that the medication should be diluted in, you guessed it, 3 mL of normal saline prior to administration via nebulizer.
In the past, concern for a rebound effect and worsening of airway obstruction after the use of racemic epinephrine has led to the recommendation that children who have been given racemic epinephrine be admitted to the hospital for observation.
Additionally, it appears to be just as, and possibly more effective than, racemic epinephrine for the treatment of croup. (It is now known that the R-Isomer of epinephrine is not actually active, meaning racemic epi is only more potent due to it’s concentration) Check out my article on Field Diagnosis and Treatment of Croup for more on this topic.
Racemic epinephrine 2.25% diluted 1:8 in saline is administered via nebulizer at a dose of 0.25 mL (4 drops) for children younger than 6 months and 0.5 mL for older children. The onset of drug action occurs in less than 10 minutes, and the effects last 60 to 90 minutes. The dose can be repeated in 1 hour.
65 Racemic epinephrine is a combination of the levorotatory and dextrorotatory forms of epinephrine, the latter being about one twelfth to one eighteenth as potent as the former.
Epinephrine racemic is used for temporary relief of symptoms associated with bronchial asthma (e.g., shortness of breath, chest tightening, wheezing) and to treat croup in children.
Injection (Adrenalin): 0.1 mg/ml, 1 mg/ml. Injection: 0.3 mg/0.3 ml (EpiPen Auto Injector), 0.15 mg/0.3 ml (EpiPen 2-Pak). Inhalation (Aerosol [Primatene Mist]): 0.2 mg/inhalation. Inhalation Solution: 1%, 2.25%....Pharmacokinetics:RouteInhalationOnset3-5 minPeak20 minDuration1-3 hr3 more columns
Racemic epinephrine has been shown to reduce length of stay, intubation rates, and ICU admissions. You may repeat dosing every 2-3 hours for a maximum of 3 total consecutive treatments; however, if you are repeating the dose for recurrent stridor after the first dose, admission is likely necessary.
Epinephrine causes vasoconstriction and decreased blood flow, which should diminish edema formation. If post-extubation stridor is due to laryngeal edema, it is hoped that epinephrine's effects will inhibit edema and relieve the airway obstruction.
albuterol racepinephrine Using albuterol together with racepinephrine may increase cardiovascular side effects such as elevations in heart rate and blood pressure or irregular heart rhythm.
Nebulized racemic epinephrine is a 1:1 mixture of dextro (D) isomers and levo (L) isomers of epinephrine with the L form (L-epinephrine) as the active component. Its use is typically reserved for patients in the hospital setting with moderate-to-severe respiratory distress.
Serious - Use Alternative (1) epinephrine racemic and amiodarone both increase QTc interval. Avoid or Use Alternate Drug.
Elicits agonistic action on alpha, beta-2, and beta-2 receptors resulting in bronchial smooth muscle relaxation, cardiac stimulation, vasodilation in skeletal muscle, and stimulation of glycogenolysis in the liver.
For oral inhalation only. Because asthma may be life threatening, instruc patient to seek immediate medial attention when not relieved within 20 minutes, feeling worse after treatment, need more inhalations than recommended for 24 hours, have more than 2 asthma attacks in a week.
Monitor Closely (1) alprazolam increases and epinephrine racemic decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor.
Monitor Closely (2) acebutolol decreases effects of epinephrine racemic by pharmacodynamic antagonism. Use Caution/Monitor.
Monitor Closely (2) bisoprolol decreases effects of epinephrine racemic by pharmacodynamic antagonism. Use Caution/Monitor.
amitriptyline increases and epinephrine racemic decreases sedation. Effect of interaction is not clear, use caution. Use Caution/Monitor. Serious - Use Alternative (2) epinephrine racemic and amitriptyline both increase QTc interval. Avoid or Use Alternate Drug.
5 Its effects last approximately 30 to 60 minutes. In the past, concern for a rebound effect and worsening of airway obstruction after the use of racemic epinephrine has led to the recommendation that children who have been given racemic epinephrine be admitted to the hospital for observation. However, research has shown that rebound rarely happens; it is probably safe to discharge patients from the emergency department if they are stable 3 hours after the administration of the racemic epinephrine. 4,5,35
Racemic epinephrine may help open up the airways by decreasing edema of the airway, although reviews of its efficacy have been negative.
Nebulized racemic epinephrine can be useful in the treatment of moderate or severe cases of LTB.66,67 The adrenergic effects of racemic epinephrine induce vasoconstriction, which decreases subglottic edema. 67 Racemic epinephrine 2.25% diluted 1:8 in saline is administered via nebulizer at a dose of 0.25 mL (4 drops) for children younger than 6 months and 0.5 mL for older children. The onset of drug action occurs in less than 10 minutes, and the effects last 60 to 90 minutes. The dose can be repeated in 1 hour. Continuous nebulization over 30 to 60 minutes may also be effective.
Drug Class: Alpha/Beta Agonists. Epinephrine racemic is used for temporary relief of symptoms associated with bronchial asthma (e.g., shortness of breath, chest tightening, wheezing) and to treat croup in children. Epinephrine racemic is available under the following different brand names: AsthmaNefrin and S2.
Use epinephrine racemic with caution during pregnancy if benefits outweigh risks. Animal studies show risk and human studies are not available or neither animal nor human studies were done.
This medication contains epinephrine racemic. Do not take AsthmaNefrin or S2 if you are allergic to epinephrine racemic or any ingredients contained in this drug. Keep out of reach of children. In case of overdose, get medical help or contact a Poison Control Center immediately.
When administered parenterally, epinephrine has a rapid onset but a short duration of action. When given intravenously, it has a half-life of fewer than 5 minutes. Metabolism is primarily in the liver, along with various other locations such as the kidneys, skeletal muscle, and mesenteric organs. It is degraded into an inactive metabolite named vanillylmandelic acid by MAO and COMT and excreted into the urine. However, a small amount of the drug is excreted unchanged as well.
Epinephrine is a hormone that produces widespread effects. Certain effects need monitoring. Tachycardia and hypertension are expected effects when giving epinephrine intravenously, so it is important to titrate the drug carefully while monitoring hemodynamics. Epinephrine is also used with anesthetic agents to provide analgesia. In locations where extravasation of epinephrine has occurred, prevention and treatment of ischemia-induced necrosis are necessary. The infiltrated area should receive treatment with a 10 mL to 15 mL saline solution containing 5 mL to 10 mg of phentolamine, an alpha-adrenergic blocking agent. A study showed how hospitalized patients in the ICU with finger ischemia were associated with the use of vasopressors, including epinephrine. [7]
Epinephrine is effective at a dilution of between 1 to 100,000 and 1 to 400,000 for mydriasis induction and maintenance in pediatric intraocular surgeries.
Epinephrine is one of the most commonly used agents in various settings as it functions as medication and hormone. It is currently FDA-approved for various situations, including emergency treatment of type 1 hypersensitivity reactions, including anaphylaxis, induction, and maintenance of mydriasis during intraocular surgeries and hypotension due to septic shock.[1] Off-label uses of epinephrine include, but are not limited to, ventricular fibrillation, pulseless ventricular tachycardia, asystole, pulseless electrical activity (PEA), croup, and severe asthma exacerbations unresponsive to standard treatment. [2][3]In the operating room (OR) setting, epinephrine is also used as a local anesthetic block. Produced by the adrenal medulla, epinephrine plays a vital role in the body’s acute stress response by stimulating the sympathetic nervous system. [4]
Interprofessional management of epinephrine therapy will yield the best patient outcomes with the fewest adverse effects. [Level 5]
For the treatment of anaphylaxis, epinephrine is preferably injected intramuscularly into the anterolateral aspect of the thigh due to rapid absorption. Subcutaneous injection is also an option. For advanced cardiovascular life support (ACLS), patients can receive epinephrine intravenously or intraosseous if needed. Another route of administration is through an endotracheal tube often used in neonatal resuscitation.
Epinephrine is one of the most commonly used agents in various settings as it functions as medication and hormone. It is currently FDA-approved for various situations, including emergency treatment of type 1 hypersensitivity reactions, including anaphylaxis, induction, and maintenance of mydriasis during intraocular surgeries and hypotension due to septic shock. It also has several off-label uses. This activity will highlight the mechanism of action, adverse event profile, pharmacology, monitoring, and relevant interactions of epinephrine, pertinent for members of the interprofessional team in treating patients with conditions where this agent is indicated.
Do you notice anything greatly different from “regular” epi? That’s right! The concentration! Racemic epinephrine is typically dispensed in a 2.25% concentration – that’s 22.5 mg/mL!!! The package instructions usually state that the medication should be diluted in, you guessed it, 3 mL of normal saline prior to administration via nebulizer.
Most of us are intimately familiar with the 1:1000 concentration of epinephrine, which is an emergency medicine staple. We know that there is 1 mg in each mL, but where does the 1000 come into play? The answer is fairly simple, but requires an explanation of a few basic assumptions about water first.
I have heard ruminations that it is possible to “make” racemic epinephrine in the field. This is just not realistic. I have been told that, in order to make racemic epinephrine, dilute 1 mL of 1:1000 epinephrine in 3 mL of normal saline. This, I believe, is where the confusion is. Take a look at the package of racemic epinephrine in the image below.
We can just think of this as “left-handed epi”. Racemic epinephrine, on the other hand (no pun intended) contains both L-Epinephrine, AND D-Epinephrine. The “D” stands for dextrorotary, which we can think of as “right-handed Epi”. The D-Epinephrine is simply a mirror image of the L-epinephrine.
Current research tells us that administering 1:1000 epinephrine can be done safely without dilution via small volume nebulizer. Additionally, it appears to be just as, and possibly more effective than, racemic epinephrine for the treatment of croup. (It is now known that the R-Isomer of epinephrine is not actually active, meaning racemic epi is only more potent due to it’s concentration) Check out my article on Field Diagnosis and Treatment of Croup for more on this topic.
1 to 3 inhalations (0.5 mL), via a hand-held rubber nebulizer, not more often than every 3 hours Maximum dose: 12 inhalations in 24 hours Use (s): Temporary relief of mild symptoms of intermittent asthma
4 years and older: 1 to 3 inhalations (0.5 mL), via a hand-held rubber nebulizer, not more often than every 3 hours Maximum dose: 12 inhalations in 24 hours Use (s): Temporary relief of mild symptoms of intermittent asthma
CONTRAINDICATIONS: None Safety and efficacy have not been established in patients younger than 4 years. Consult WARNINGS section for additional precautions.
Administration advice: -Do not use more than directed. -Adults should supervise use of this product by children. Storage requirements: -Protect from light. -Avoid excessive heat. -Protect from freezing. Reconstitution/preparation techniques: -Add 0.5 mL (1 vial) to a handheld rubber bulb nebulizer for administration. Patient advice: -See a doctor if you are not better within 20 minutes of using this drug, if your asthma gets worse, if you need more than 12 inhalations in 24 hours, if you need this drug 3 or more days a week, or if you have more than 2 asthma attacks in a week. -Do not use this drug if you are taking a monoamine oxidase inhibitor (MAOI), or within 2 weeks of stopping a MAOI. -Stop this drug and ask your doctor if your asthma is getting worse, you have difficulty sleeping, you have a rapid heartbeat, or if you have tremors, nervousness, or seizures..
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.