EPINEPHrine

EPINEPHrine

Indication

• Cardiac resuscitation to restore myocardial contractility and increase heart rate
• Treatment of hypotension; especially in the context of suspected or confirmed myocardial dysfunction
• Treatment of respiratory distress due to bronchospasm and subepiglottal stenosis and edema following extubation

Dosage Guidelines

• Resuscitation

  • IV (preferred route): 0.2 mL/kg (0.02 mg/kg/dose) q3-5 minutes prn
  • ETT:  1 mL/kg (0.1 mg/kg/dose) q3-5 minutes prn until IV access obtained

• Hypotension/shock

  • Continuous infusion: 0.01 – 0.2 microgram/kg/min IV. 
  • While neonatal pharmacological data is scarce, a dose range of 0.01 to 0.1 mcg/kg/min is intended for beta receptor predominant action to promote myocardial contractility. Titrate to response every 15 to 30 minutes. Doses exceeding 0.1 mcg/kg/min should be used with caution and warrants careful assessment of neonatal hemodynamics.

• Respiratory Distress/Subepiglottal Stenosis and Edema

  • Less than 5 kg: 0.5 mg/kg/dose
  • Greater than or equal to 5 kg: 2.5-5 mg/dose
  • Dilute dose to 2.5 or 3 mL in normal saline. Administer via nebulizer prn to maximum q1 hour
    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

Administration

• ETT
• Inhalation
• IV direct; Follow or dilute dose with normal saline 3 mL
• IV continuous infusion

• For patients 1 kg or less:

  Use EPINEPHrine 8 mcg/mL

  To make 50 mL of EPINEPHrine [8 mcg/mL] [0.4 mg/50 mL]:

  Add 0.4 mL (0.4 mg) of EPINEPHrine [1 mg/mL] to 49.6 mL of solution

• For patients over 1 kg to 3 kg:

  Use EPINEPHrine 16 mcg/mL

  To make 50 mL of EPINEPHrine [16 mcg/mL] [0.8 mg/50 mL]:

  Add 0.8 mL (0.8 mg) of EPINEPHrine [1 mg/mL] to 49.2 mL of solution

• For Patients over 3 kg:

  Use EPINEPHrine 32 mcg/mL

  To make 50 mL of EPINEPHrine [32 mcg/mL] [1.6 mg/50 mL]:

  Add 1.6 mL (1.6 mg) of EPINEPHrine [1 mg/mL] to 48.4 mL of solution

• Administer via central line whenever possible

Adverse Effects

• Cardiac arrythmias, renal vascular ischemia, hypertension with cerebral hemorrhage and tissue necrosis with local infiltration.
• Hyperglycemia and hyperlactatemia are known sequalae of epinephrine infusion 

Comments

• Vasoconstriction predominates over vasodilation at higher doses. Epinephrine at greater than 0.5 mcg/kg/min causes excessive vasoconstriction and possibly disorganized energy utilization leading to a decreased cardiac output.
• ETT route may lead to lower plasma concentrations
• Monitor IV site for extravasation.  If extravasation occurs, consider use of phentolamine
• There may be a modest decrease in pulmonary vascular resistance as well as vasodilation of renal and mesenteric vasculature at low doses.

Supplied As

• 1 mg/mL amp
• 1 mg/10 mL syringe
• 1 mg/mL topical solution for inhaled use
• Supplied by Pharmacy as standard concentrations of 8 mcg/mL (supplied as 50 mg/50 mL of IV fluid ordered), 16 mcg/mL (0.8 mg/50 mL of IV fluid ordered) and 32 mcg/mL (supplied as 1.6 mg/50 mL of IV fluid ordered)
• At LHSC, standard concentration reference charts are available on the NICU Intranet site

References

LexiComp (Hospital for Sick Children), LexiComp Pediatric and Neonatal, Joynt C, Cheung PY. Treating Hypotension in Preterm Neonates with Vasoactive Medications. Front Pediatr. 2018 Apr 13; 6:86