Epinephrine

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 ) 1.1 Hypotension associated with Septic Shock Epinephrine Injection USP, 1 mg/10 mL (0.1 mg/mL) is indicated to increase mean arterial blood pressure in adult patients with hypotension associated with septic shock.

• Hypotension associated with septic shock : o Dilute epinephrine in dextrose solution 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
• General Considerations Inspect visually for particulate matter and discoloration prior to administration, whenever solution and container permit
• Do not use if the solution is colored or cloudy, or if it contains particulate matter
• Discard any unused portion
• Hypotension associated with Septic Shock Dilute epinephrine in 5% Dextrose Injection, USP or 5% Dextrose and Sodium Chloride solution
• These dextrose containing fluids provide protection against significant loss of potency by oxidation
• Administration in saline solution alone is not recommended
• If indicated, administer whole blood or plasma separately
• Add the entire contents of epinephrine prefilled syringe to 1000 mL of a 5% Dextrose containing solution
• Each mL of this dilution contains 1 mcg of epinephrine
• 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 diseases. …

Injection: 10 mL single-dose prefilled syringe containing 1 mg/10 mL (0.1 mg/mL) epinephrine as the hydrochloride in a sterile, clear and colorless solution. Injection: 1 mg/10 mL (0.1 mg/mL) single-dose prefilled syringe.

• Safety and effectiveness of epinephrine
• In pediatric patients with septic shock have not been established

Clinical studies of epinephrine for the treatment of hypotension associated with septic shock did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. …

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Drugs that counter the pressor effects of epinephrine include alpha blockers, vasodilators such as nitrates, diuretics, antihypertensives, and ergot alkaloids. ( 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. …

• Monitor blood pressure frequently. (5.1) • Increases cardiac output and causes peripheral vasoconstriction. (5.2) • May induce cardiac arrhythmias and myocardial ischemia. (5.3) • Avoid extravasation into tissues, which can cause local necrosis. (5.4) • Constricts renal blood vessels which may result in oliguria or renal impairment. (5.5) • Sulfite Warning. (5.6) 5.1 Hypertension Because individual response to epinephrine may vary significantly, monitor blood pressure frequently and titrate to avoid excessive increases in blood pressure. …

The following adverse reactions are discussed elsewhere in labeling: • Hypertension [see Warnings and Precautions (5.1)] • Pulmonary Edema [see Warnings and Precautions (5.2)] • Cardiac Arrhythmias and Ischemia [see Warnings and Precautions (5.3)] • Extravassation and Tissue Necrosis with Intravenous Infusion [see Warnings and Precautions (5.4)] • Renal Impairment [see Warnings and Precautions (5.5)] • Allergic Reactions associated with Sulfite [see Warnings and Precautions (5.6)] The following adverse reactions associated with the infusion of epinephrine were identified in the literature. …

8.1 Pregnancy Risk Summary Limited published data on epinephrine use in pregnant women are not sufficient to determine a drug-associated risk for major birth defects or miscarriage. However, there are risks to the mother and fetus associated with epinephrine use during labor or delivery, and risks due to untreated hypotension associated with septic shock (see Clinical Considerations) . …

Overdosage of epinephrine may produce extremely elevated arterial pressure, which may result in cerebrovascular hemorrhage, particularly in elderly patients. Overdosage may also result in pulmonary edema because of peripheral vascular constriction together with cardiac stimulation. Epinephrine overdosage may also cause transient bradycardia followed by tachycardia and these may be accompanied by potentially fatal cardiac arrhythmias. …

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