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adrenaline

adrenaline / epinephrine

presentation

  • ampoules for parenteral use:
    • 1:1000 = 1mg in 1ml
    • 1:10,000 = 1mg in 10ml (also available as a Minijet)
  • Epipen = 300 microgram in 0.3ml
  • Epipen junior = 150 microgram in 0.3ml for use in children with weight 15-30kg
  • nebuliser solution (L-adrenaline) = 1% = 10mg/ml

dosage and usages

cardiac arrest - asystole or EMD:

anaphylaxis:

  • see also anaphylaxis
  • 1:1000 im 0.01ml/kg to maximum 0.5ml (Adult 0.5ml) im into lateral thigh, repeat after 5min if no improvement
    • do not give s/c as absorption is unreliable
    • do not give iv adrenaline bolus doses unless arrest imminent
    • if hypotensive:
      • elevate legs, lie patient flat
      • iv fluid boluses of 10-20ml/kg 0.9% saline
    • if upper airway obstruction, consider nebulised adrenaline as for croup (below) in addition to im adrenaline
    • if inadequate response to repeat im adrenaline dose:
      • commence iv adrenaline infusion at 0.05-1.0mcg/kg/min (see below as for infusions)
    • if airway obstruction not settling, consider early intubation and rapid sequence induction (RSI) for emergency intubation
    • if requires 2 or more adrenaline doses or more than 20ml/kg saline, contact ICU
  • and give methylprednisolone iv 1mg/kg or hydrocortisone

croup:

  • neb: 1ml of 1% adrenaline (L-isomer) diluted to 4mls with N Saline, or,
    • or 1:1000 adrenaline neb 0.5ml/kg up to 6ml
  • also give prednisolone 1mg/kg orally or dexamethasone 0.6mg/kg im
  • see also croup

iv infusions

general principles

  • adrenaline is compatible with 0.9% saline or 5% dextrose / glucose
  • should preferably be given via a central line although a large peripheral vein may be used.
  • peripheral line administration in adults:
    • requires regular checking to ensure extravasation at the site is not occurring
      • extravasation causes local vasoconstriction and risks tissue necrosis
      • if extravasation occurs, the line should be re-sited elsewhere and consider use of topical GTN to help reduce the local vasoconstriction although there is little evidence of benefit.
    • to reduce risk, concentration should be 1mg adrenaline in 1000ml if volume load is not an issue (eg. adult asthma)
    • where volume load is an issue such as in patients with cardiac or renal impairment, concentrations of 2mg adrenaline in 500ml may be used in a peripheral line.
  • central line administration in adults:
    • usual concentration for ward and CCU patients is 2mg adrenaline in 500ml
    • critically ill patients in ED or ICU in whom fluid load is a major concern, can be given 6mg adrenaline in 100ml = 60 microgram/ml, thus, 1ml/hour = 1 microgram/minute
  • patients on adrenaline infusions require close monitoring:
    • hourly vital signs until stable then 4 hourly if only for bronchodilator use (max. rate in adults on wards = 3 microgram/minute)
    • continuous vital sign and ECG monitoring for critically ill patients, preferably with arterial line BP monitoring if inotrope use.
  • prepared infusions should be covered from light, and will be stable for 24 hours only.
  • administration should be via an IMED pump or similar
  • should not be given through the same line as other drugs or fluids to prevent inadvertent doses of adrenaline being administered.

paediatric inotrope infusion:

  • 0.3mg/kg adrenaline made up to 50ml with 5% glucose
  • when running at 1ml/hr = 0.1 microgram/kg/min
  • for circulatory support, usual dose is 0.05-1.0 mcg/kg/min = 0.5-10ml/hr
  • NB. iv salbutamol is the preferred iv bronchodilator in children with severe - see Mx of critically severe paediatric asthma

adult inotrope infusion:

  • dose: 0.25mcg/min increase by 0.25mcg/min increments
  • if large peripheral line or central line administration:
    • use *2mg adrenaline (2ml of 1:1000) in 500ml saline or 5% glucose
    • 4 micrograms / ml, thus 15ml/hour = 1 microgram/minute
    • thus 0.25 mcg/minute dose increments = 3.75ml/hr
  • if central line administration where minimising volume dosing is absolutely critical:
    • use 6mg adrenaline in 100ml 0.9% saline or 5% glucose
    • 60 microgram/ml, thus, 1ml/hour = 1 microgram/minute
    • thus 0.25 mcg/minute dose increments = 0.25ml/hr

adult bronchodilator infusion:

  • dose: 1-2mcg/min
  • if general ward administration via peripheral line:
    • 1mg adrenaline (1ml of 1:1000) in 1000ml 0.9% saline (cover from light)
    • 1 microgram/ml ⇒ run at 1-2ml/min = 60-120ml/hr
  • if general ward administration via central line or ED/CCU/ICU use with peripheral or central line:
    • 2mg adrenaline (2ml of 1:1000) in 500ml 0.9% saline (cover from light)
    • 4 microgram/ml ⇒ run at 0.25-0.50ml/min = 15-30ml/hr
  • maximum rate on general wards = 3mcg/min
  • see also asthma

brief summary of actions

  • see sympathomimetics for details
  • vasoconstriction thus cold, pale peripheries
  • tachycardia
  • increased systolic blood pressure and increased pulse pressure
    • although slow infusion may cause fall in diastolic BP due to beta vasoconstriction in skeletal muscle and thus mean arterial pressure (MAP) may remain unchanged and thus no vagal response which may otherwise cause a reflex bradycardia
  • bronchodilatation (via beta 2 agonist)

adverse effects

  • increased myocardial oxygen consumption which, combined with chronotropic effect, may lead to:
  • restlessness, anxiety
  • tremors, dizziness, headache
  • inadvertent IV administration of SC dose:
    • alarming increased systolic & diastolic BP ⇒ cerebrovascular haemorrhage
  • necrosis if injection into end artery regions (eg. fingers, tip of nose):
    • risk of vasospastic ischaemia leading to gangrene
  • pulmonary oedema due to increased pulmonary capillary filtration pressure because of increased constriction great veins + pulmonary vasoconstriction
  • hyperglycaemia
  • hypokalaemia
  • lactic acidosis

references and other resources

adrenaline.txt · Last modified: 2019/08/04 14:16 (external edit)