General MedicationsINTRAMUSCULAR / INTRAVENOUS / SUBCUTANEOUSHigh Alert

epinephrine

EPINEPHRINE

Standard Dose

2 DOSAGE AND ADMINISTRATION • Hypotension associated with septic shock ( 2.2 ): o Dilute epinephrine in 5% Dextrose Injection or 5% Dextrose and 0.9% Sodium Chloride Injection prior to infusion. o Infuse epinephrine into a large vein. o Titrate 0.05 mcg/kg/min to 2 mcg/kg/min to achieve desired blood pressure. o Wean gradually. • Anaphylaxis ( 2.3 ): o Administer undiluted Epinephrine Injection intramuscularly or subcutaneously into anterolateral thigh every 5 to 10 minutes as needed o Adult and pediatric patients 30 kg or greater: 0.3 mg to 0.5 mg (0.3 mL to 0.5 mL) o Pediatric patients under 30 kg: 0.01 mg/kg (0.01 mL/kg) 2.1 General Considerations Inspect visually for particulate matter and discoloration prior to administration, solution should be clear and colorless. Do not use if the solution is colored or cloudy, or if it contains particulate matter. Discard any unused portion. 2.2 Recommended Dosage and Administration Instructions for Hypotension associated with Septic Shock Dilute 1 mL of epinephrine 1 mg/mL (1 mg) in 1,000 mL of 5% Dextrose Injection or 5% Dextrose and 0.9% Sodium Chloride Injection to produce a 1 mcg per mL dilution. The diluted solutions can be stored for up to 6 hours at room temperature (20°C to 25°C) or 24 hours under refrigerated conditions (2°C to 8°C). Administration in 0.9% Sodium Chloride Injection alone is not recommended. If indicated, administer whole blood or plasma separately. Whenever possible, give infusions of epinephrine into a large vein. Avoid using a catheter tie-in technique, because the obstruction to blood flow around the tubing may cause stasis and increased local concentration of the drug. Avoid the veins of the leg in elderly patients or in those suffering from occlusive vascular disorders. To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min and is titrated to achieve a desired mean arterial pressure (MAP). The dosage may be adjusted periodically, such as every 10 to 15 minutes, in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min, to achieve the desired blood pressure goal. The ideal body weight (IBW) should be used as the weight parameter for dosing epinephrine in adult patients with septic shock associated hypotension. After hemodynamic stabilization, wean incrementally over time, such as by decreasing doses of epinephrine every 30 minutes over a 12 to 24 hour period. 2.3 Recommended Dosage and Administration Instructions for Anaphylaxis The recommended dosage of Epinephrine Injection is based on weight and is provided in Table 1. Administer undiluted Epinephrine Injection intramuscularly or subcutaneously in the anterolateral aspect of the thigh. Table 1 Recommended Dosage of Epinephrine Injection in Adult and Pediatric Patients for Anaphylaxis Dosage Maximum Dosage Adult and Pediatric Patients Weighing 30 kg or Greater 0.3 mg to 0.5 mg (0.3 mL to 0.5 mL) of undiluted Epinephrine Injection 0.5 mg (0.5 mL) per injection Pediatric Patients Weighing Less Than 30 kg 0.01 mg/kg (0.01 mL/kg) of undiluted Epinephrine Injection 0.3 mg (0.3 mL) per injection • In the absence of clinical improvement or if symptoms worsen after the initial treatment, additional doses of Epinephrine Injection may be repeated every 5 to 10 minutes as necessary. • Monitor clinically for cardiac effects. Administration Instructions • For intramuscular administration, use a needle long enough (at least 1/2 inch to 5/8 inch) to ensure the injection is administered into the muscle. • To minimize the risk of injection related injury to a pediatric patient, hold the leg firmly in place and limit movement prior to and during an injection. • Inject Epinephrine Injection intramuscularly or subcutaneously into the anterolateral aspect of the thigh, through clothing if necessary. Do not inject intravenously, and do not inject into buttocks, into digits, hands or feet. • Do not administer repeated injections at the same site, as the resulting vasoconstriction may cause tissue necrosis.

Max Dose

See official label

Primary Use

1 INDICATIONS AND USAGE Epinephrine is a non-selective alpha and beta adrenergic agonist indicated: • To increase mean arterial blood pressure in adult patients with hypotension associated with septic shock.

Summary

Dosage and administration 2 DOSAGE AND ADMINISTRATION • Hypotension associated with septic shock ( 2.2 ): o Dilute epinephrine in 5% Dextrose Injection or 5% Dextrose and 0.9% Sodium Chloride Injection prior to infusion. o Infuse epinephrine into a large vein. o Titrate 0.05 mcg/kg/min to 2 mcg/kg/min to achieve desired blood pressure. o Wean gradually. • Anaphylaxis ( 2.3 ): o Administer undiluted Epinephrine Injection intramuscularly or subcutaneously into anterolateral thigh every 5 to 10 minutes as needed o Adult and pediatric patients 30 kg or greater: 0.3 mg to 0.5 mg (0.3 mL to 0.5 mL) o Pediatric patients under 30 kg: 0.01 mg/kg (0.01 mL/kg) 2.1 General Considerations Inspect visually for particulate matter and discoloration prior to administration, solution should be clear and colorless.

Structured Monograph

Clinical summary

Indications and usage 1 INDICATIONS AND USAGE Epinephrine is a non-selective alpha and beta adrenergic agonist indicated: • To increase mean arterial blood pressure in adult patients with hypotension associated with septic shock. ( 1.1 ) • For emergency treatment of type 1 allergic reactions, including anaphylaxis in adult and pediatric patients. ( 1.2 ) 1.1 Hypotension associated with Septic Shock Epinephrine Injection is indicated to increase mean arterial blood pressure in adult patients with hypotension associated with septic shock. 1.2 Anaphylaxis Epinephrine Injection is indicated for emergency treatment of type I allergic reactions, including anaphylaxis in adult and pediatric patients. Dosage and administration 2 DOSAGE AND ADMINISTRATION • Hypotension associated with septic shock ( 2.2 ): o Dilute epinephrine in 5% Dextrose Injection or 5% Dextrose and 0.9% Sodium Chloride Injection prior to infusion. o Infuse epinephrine into a large vein. o Titrate 0.05 mcg/kg/min to 2 mcg/kg/min to achieve desired blood pressure. o Wean gradually. • Anaphylaxis ( 2.3 ): o Administer undiluted Epinephrine Injection intramuscularly or subcutaneously into anterolateral thigh every 5 to 10 minutes as needed o Adult and pediatric patients 30 kg or greater: 0.3 mg to 0.5 mg (0.3 mL to 0.5 mL) o Pediatric patients under 30 kg: 0.01 mg/kg (0.01 mL/kg) 2.1 General Considerations Inspect visually for particulate matter and discoloration prior to administration, solution should be clear and colorless. Do not use if the solution is colored or cloudy, or if it contains particulate matter. Discard any unused portion. 2.2 Recommended Dosage and Administration Instructions for Hypotension associated with Septic Shock Dilute 1 mL of epinephrine 1 mg/mL (1 mg) in 1,000 mL of 5% Dextrose Injection or 5% Dextrose and 0.9% Sodium Chloride Injection to produce a 1 mcg per mL dilution. The diluted solutions can be stored for up to 6 hours at room temperature (20°C to 25°C) or 24 hours under refrigerated conditions (2°C to 8°C). Administration in 0.9% Sodium Chloride Injection alone is not recommended. If indicated, administer whole blood or plasma separately. Whenever possible, give infusions of epinephrine into a large vein. Avoid using a catheter tie-in technique, because the obstruction to blood flow around the tubing may cause stasis and increased local concentration of the drug. Avoid the veins of the leg in elderly patients or in those suffering from occlusive vascular disorders. To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min and is titrated to achieve a desired mean arterial pressure (MAP). The dosage may be adjusted periodically, such as every 10 to 15 minutes, in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min, to achieve the desired blood pressure goal. The ideal body weight (IBW) should be used as the weight parameter for dosing epinephrine in adult patients with septic shock associated hypotension. After hemodynamic stabilization, wean incrementally over time, such as by decreasing doses of epinephrine every 30 minutes over a 12 to 24 hour period. 2.3 Recommended Dosage and Administration Instructions for Anaphylaxis The recommended dosage of Epinephrine Injection is based on weight and is provided in Table 1. Administer undiluted Epinephrine Injection intramuscularly or subcutaneously in the anterolateral aspect of the thigh. Table 1 Recommended Dosage of Epinephrine Injection in Adult and Pediatric Patients for Anaphylaxis Dosage Maximum Dosage Adult and Pediatric Patients Weighing 30 kg or Greater 0.3 mg to 0.5 mg (0.3 mL to 0.5 mL) of undiluted Epinephrine Injection 0.5 mg (0.5 mL) per injection Pediatric Patients Weighing Less Than 30 kg 0.01 mg/kg (0.01 mL/kg) of undiluted Epinephrine Injection 0.3 mg (0.3 mL) per injection • In the absence of clinical improvement or if symptoms worsen after the initial treatment, additional doses of Epinephrine Injection may be repeated every 5 to 10 minutes as necessary. • Monitor clinically for cardiac effects. Administration Instructions • For intramuscular administration, use a needle long enough (at least 1/2 inch to 5/8 inch) to ensure the injection is administered into the muscle. • To minimize the risk of injection related injury to a pediatric patient, hold the leg firmly in place and limit movement prior to and during an injection. • Inject Epinephrine Injection intramuscularly or subcutaneously into the anterolateral aspect of the thigh, through clothing if necessary. Do not inject intravenously, and do not inject into buttocks, into digits, hands or feet. • Do not administer repeated injections at the same site, as the resulting vasoconstriction may cause tissue necrosis. Warnings and cautions 5 WARNINGS AND PRECAUTIONS • Do not inject intravenously, into buttocks, digits, hands, or feet. ( 5.1 ) • Rare cases of serio

Monitoring

• 5 WARNINGS AND PRECAUTIONS • Do not inject intravenously, into buttocks, digits, hands, or feet.
• ( 5.1 ) • Rare cases of serious skin and soft tissue infections have been reported following epinephrine injection ( 5.2 ) • Avoid extravasation into tissues, which can cause local necrosis.
• ( 5.3 ) • Monitor patient for acute severe hypertension.
• ( 5.4 ) • Potential for pulmonary edema, which may be fatal.

Interaction Notes

• 7 DRUG INTERACTIONS • Drugs that counter the pressor effects of epinephrine include alpha blockers, vasodilators such as nitrates, diuretics, antihypertensives, ergot alkaloids, and phenothiazine antipsychotics.
• ( 7.1 ) • Drugs that potentiate the effects of epinephrine include sympathomimetics, beta blockers, tricyclic antidepressants, MAO inhibitors, COMT inhibitors, clonidine, doxapram, oxytocin, levothyroxine sodium, and certain antihistamines.
• ( 7.2 ) • Drugs that increase the arrhythmogenic potential of epinephrine include beta blockers, cyclopropane and halogenated hydrocarbon anesthetics, quinidine, antihistamines, exogenous thyroid hormones, diuretics, and cardiac glycosides.
• Observe for development of cardiac arrhythmias.