ADMINISTRATION ROUTES:
IV, IM, SC, Nebulised, Endotracheal
ALTERNATIVE NAMES:
Adrenaline mini-jet, EpiPen, Anapen, Epinephrine
ICU INDICATIONS:
-
Cardiac arrest
-
Anaphylaxis
-
Upper airway obstruction
-
Inotrope / vasopressor
PRESENTATION AND ADMINISTRATION:
IV:
Adrenaline comes in vials containing 1mg in 1 mL (1:1000) and vials containing 1mg in 10 mL (1:10,000). Mini-jets that contain 1mg in 10 mL are also available.
The standard dilution for adrenaline by infusion in the ICU is 10 mg in 100 mL of compatible IV fluid
Compatible with the following IV fluids:
Normal saline, 5% dextrose, Glucose and Sodium Chloride, Hartmann’s
Store at room temperature. Protect from light. Do not refrigerate. Solutions that are discoloured pink or brown should not be used.
IM:
Although IM use is said to be preferred in anaphylaxis and other emergencies, the IV route is generally more appropriate in the ICU setting. Use 1:1000 solution undiluted for administration by the IM route.
Nebulised
Use 1:1000 solution and (if required) make up to a total of 5 mL using Normal saline prior to administration
DOSAGE:
Cardiac arrest:
10 mL of 1:10,000 (i.e 1 mg) IV
OR
3-10 mg of 1:1000 via endotracheal tube if IV access cannot be obtained
Note: in cardiac arrest after cardiac surgery, consideration should be given to immediate sternotomy. If adrenaline is administered in this setting, a standard 1mg dosage is inappropriate due to the risk of rebound hypertension leading to fatal haemorrhage. Give bolus doses of 1 mL of 1:10,000 and uptitrate gently if circulation is not restored
Anaphylaxis:
0.05 mL/kg of 1:10,000 IV with dose titrated to effect followed by IV infusion if required
OR
0.01 mL/kg of 1:1000 IM (avoid administration in the buttocks)
Post-extubation stridor or other upper airway obstruction:
Use the 1:1000 vials up to maximum dose 5 mL and administer via a nebuliser. If giving less than 4 mg, make up to at least 4 mL with 0.9% saline
IV Infusion:
10 mg in 100 mL of 5% dextrose or Normal saline at up to 20 mL/hr titrated to effect
DOSAGE IN RENAL FAILURE AND RENAL REPLACEMENT THERAPY:
No dosage adjustment is required in renal failure or renal replacement therapy
DOSAGE IN PAEDIATRICS:
Cardiac arrest:
0.1 mL/kg of 1:10,000 IV
0.1 mL/kg of 1:1000 via endotracheal tube
Anaphylaxis:
0.05 mL/kg of 1:10,000 IV
OR
0.01 mL/kg of 1:1000 IM
Severe Croup:
Use the 1:1000 vials at a dose of 0.5 mL/kg/dose, maximum dose 5 mL and administer via a nebuliser. Make up to at least 4 mL with 0.9% saline
IV Infusion:
0.3 mg/kg in 50 mL 5% dextrose at 0.5-10 mL/hr (equates to 0.05-1 mcg/kg/min)
CLINICAL PHARMACOLOGY:
Adrenaline is a sympathomimetic drug. It activates an adrenergic receptive mechanism on effector cells and imitates all actions of the sympathetic nervous system except those on the arteries of the face and sweat glands. Adrenaline acts on both alpha and beta receptors
CONTRAINDICATIONS:
There are no absolute contraindications to the use of adrenaline in a life-threatening situation
WARNINGS:
Adrenaline by infusion commonly leads to hyperlactataemia and hyperglycaemia. Adrenaline by infusion may worsen dynamic outflow tract obstruction and paradoxically reduce cardiac output (particularly if used in the setting of hypovolaemia)
PRECAUTIONS:
General:
Some patients may be at greater risk of developing adverse reactions after adrenaline administration. These include hyperthyroid individuals, individuals with cardiovascular disease, hypertension, or diabetes, and the elderly
Laboratory Tests:
Adrenaline infusion commonly leads to increased lactate. It may be necessary to measure lactate levels if there are clinical concerns.
Drug/Laboratory Test Interactions: None reported
IMPORTANT DRUG INTERACTIONS IN ICU:
The effects of adrenaline may be potentiated by tricyclic antidepressants and monoamine oxidase inhibitors.
ADVERSE REACTIONS:
Body as a Whole:
Apprehension, nervousness, anxiety and sweating.
Cardiovascular System:
Palpitations, tachycardia, pallor.
Respiratory System:
Hyperventilation, pulmonary oedema
Digestive System:
Nausea and vomiting,
Nervous System:
Headache, tremor, dizziness, weakness, cerebrovascular haemorrhage