EPINEPHRINE (Adrenalin)

• Stimulates beta adrenergic receptors
  • increases myocardial contractility, positive chronotrope, positive dromotrope, bronchodilator
  • used to treat bradycardias, severe left ventricular dysfunction or anaphylaxis
• Stimulates alpha adrenergic receptors 
  • vasoconstriction
  • used in profound hypotension or pulseless cardiac arrest to promote systemic and cerebral perfusion pressure gradient

CARDIAC ARREST

• IV direct:
  • 1 mg IV direct 
  • Cardiac Arrest: repeat every 3 to 5 minutes until return of spontaneous circulation
• IV infusion:
  • 1-4 mcg/min (beta dose) titrated to effect
  • >20 mcg/min dose titrated to effect (alpha dose)
• Endotracheal:
  • 2-2.5 mg diluted in 10 mL sodium chloride 0.9%

ANAPHYLAXIS

0.3 - 0.5 mg (0.3 - 0.5 m) repeated every 5-15 minutes (IV preferred; same dose for IM)

• Protect from light
• Should be weaned off
• Hypovolemia, hypoxemia and acidosis should be corrected concurrently with initiation of therapy
• Monitor venous oxygen saturation and lactate to guide optimal dose; higher doses associated with lactic acidosis and increased myocardial oxygen demand

• Pheochromocytoma

These are relative contraindications and would not usually apply during resuscitation:

• Hypersensitivity to epinephrine or components (contains a sulfite preservative) 
• Cardiac dilatation
• Coronary insufficiency
• Narrow angle glaucoma

• Tachycardias
• Arrhythmias
• Lactic acidosis
• Increased myocardial oxygen demand
• Hypertension
• Hyperglycemia
• Hypokalemia
• Acute kidney injury (decreased renal blood flow)
• Acute urinary retention (patients with bladder outflow obstruction)
• Mesenteric ischemia (decreased splanchnic blood flow)
• Headache, agitation/anxiety
• Nausea
• Precipitation or exacerbation of narrow-angle glaucoma
• Extravasation of drug may cause severe tissue necrosis (Rx with 5-15 mg phentolamine in NS - see phentolamine monograph)

Special Risk for Torsades de Pointes (TdP):

Epinephrine does not prolong the QT interval, BUT has a special risk of TdP because of its other actions; it should be avoided in patients with Congenital Prolonged QT Syndrome (CLQTS). Physicians with expertise in the treatment of these arrhythmias may prescribe epinephrine to carefully selected patients with CLQTS.

• epinephrine + beta blockers = decreased contractility and blood pressure
• epinephrine + other sympathomimetics = increased toxicity
• epinephrine + inhaled anaesthetics = increased myocardial irritability and risk of arrhythmias

• IV insertion site
• Continuous heart rate and rhythm
• Blood Pressure
• Lactate 
• Central or mixed venous oxygen saturation
• Blood gases
• Hourly urine output
• Blood glucose
• Urea, creatinine
• Electrolytes
• Changes in skin temperature or color
• Breath sounds/oxygen saturation if used for treatment of asthma/anaphylaxis

• Epinephrine is a vesicant; ensure line patency before and after administration.
• May be administered IV direct or by endotracheal tube by Medical Directive for pulseless ventricular tachycardia or ventricular fibrillation by an ACLS certified nurse or RRT.
• May be administered IV direct, by IV infusion or by endotracheal tube by a nurse in Adult Critical Care with an order.
• May be titrated by a nurse in Adult Critical Care.
• Must be administered via central venous access device; in emergency situations may be temporarily infused through a peripheral vascular access device until a central venous line can be established. Monitor peripheral site closely and document Infiltration and Phlebitis scale Q1H. Knowledge of the treatment for infiltration of vasoconstricting drugs is required. 
• Patients requiring continuous infusions require the placement of an arterial line to monitor BP.
• Continuous infusions must be administered by infusion device and the pump library must be enabled.
• Should not be infused via the proximal injectate port (blue) of a pulmonary artery catheter. If this is the only available central venous line, it may be administered through the proximal injectate port but thermodilution cardiac output measurements must not be measured during infusion.