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1 High Alert TIME/ACTION PROFILE (bronchodilation)


ROUTE ONSET PEAK DURATION PDF Page #1
EPINEPHrine (ep-i-nef-rin) Inhaln 1 min unknown 13 hr
Adrenalin, Allerject, Anapen, AsthmaNefrin, EpiPen, racepinephrine, S-2 Subcut 510 min 20 min 14 hr
(racepinephrine) IM 612 min unknown 14 hr
Classification IV rapid 20 min 2030 min
Therapeutic: antiasthmatics, bronchodilators, vasopressors
Pharmacologic: adrenergics Contraindications/Precautions
Pregnancy Category C Contraindicated in: Hypersensitivity to adrenergic amines; Some products may
contain bisulfites or fluorocarbons (in some inhalers) and should be avoided in pa-
tients with known hypersensitivity or intolerance.
Indications Use Cautiously in: Cardiac disease (angina, tachycardia, MI); Hypertension; Hy-
Subcut, IV, Inhaln: Management of reversible airway disease due to asthma or perthyroidism; Diabetes; Cerebral arteriosclerosis; Glaucoma (except for ophthal-
COPD. Subcut, IM, IV: Management of severe allergic reactions. IV, Intracardiac, mic use); Excessive use may lead to tolerance and paradoxical bronchospasm (in-
Intratracheal, Intraosseous (part of advanced cardiac life support [ACLS] haler); OB: Use only if potential maternal benefit outweighs potential risks to fetus;
and pediatric advanced life support [PALS] guidelines): Management of car- Lactation: High intravenous doses of epinephrine mightpmilk production or let-
diac arrest (unlabeled). Inhaln: Management of upper airway obstruction and down. Low-dose epidural, topical, inhaled or ophthalmic epinephrine are unlikely to
croup (racemic epinephrine). Local/Spinal: Adjunct in the localization/prolonga- interfere with breast feeding (NIH); Geri: More susceptible to adverse reactions;
tion of anesthesia. may requirepdose.
Action Adverse Reactions/Side Effects
Results in the accumulation of cyclic adenosine monophosphate (cAMP) at beta-ad- CNS: nervousness, restlessness, tremor, headache, insomnia. Resp: PARADOXICAL
renergic receptors. Affects both beta1(cardiac)-adrenergic receptors and BRONCHOSPASM (EXCESSIVE USE OF INHALERS). CV: angina, arrhythmias, hypertension,
beta2(pulmonary)-adrenergic receptor sites. Produces bronchodilation. Also has al- tachycardia. GI: nausea, vomiting. Endo: hyperglycemia.
pha-adrenergic agonist properties, which result in vasoconstriction. Inhibits the re-
lease of mediators of immediate hypersensitivity reactions from mast cells. Thera- Interactions
peutic Effects: Bronchodilation. Maintenance of heart rate and BP. Localization/ Drug-Drug: Concurrent use with other adrenergic agents will have additive ad-
prolongation of local/spinal anesthetic. renergic side effects. Use with MAO inhibitors may lead to hypertensive crisis. Beta
blockers may negate therapeutic effect. Tricyclic antidepressants enhance pres-
Pharmacokinetics sor response to epinephrine.
Absorption: Well absorbed following subcut administration; some absorption may Drug-Natural Products: Use with caffeine-containing herbs (cola nut, guar-
occur following repeated inhalation of large doses. ana, mate, tea, coffee)qstimulant effect.
Distribution: Does not cross the blood-brain barrier; crosses the placenta and en-
ters breast milk. Route/Dosage
Metabolism and Excretion: Action is rapidly terminated by metabolism and up- Subcut, IM (Adults): Anaphylactic reactions/asthma 0.1 0.5 mg (single dose
take by nerve endings. not to exceed 1 mg); may repeat q 10 15 min for anaphylactic shock or q 20 min 4
Half-life: Unknown. hr for asthma.
Canadian drug name. Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough Discontinued.
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2 Observe for paradoxical bronchospasm (wheezing). If condition occurs,


withhold medication and notify health care professional immediately.
Subcut (Children 1 mo): Anaphylactic reactions/asthma 0.01 mg/kg (not Observe patient for drug tolerance and rebound bronchospasm. Patients requir- PDF Page #2
to exceed 0.5 mg/dose) q 15 min for 2 doses, then q 4 hr. ing more than 3 inhalation treatments in 24 hr should be under close supervision.
IV (Adults): Severe anaphylaxis 0.1 0.25 mg q 5 15 min; may be followed by If minimal or no relief is seen after 3 5 inhalation treatments within 6 12 hr, fur-
1 4 mcg/min continuous infusion; cardiopulmonary resuscitation (ACLS guide- ther treatment with aerosol alone is not recommended.
lines) 1 mg q 3 5 min; bradycardia (ACLS guidelines) 2 10 mcg/min). Assess for hypersensitivity reaction (rash; urticaria; swelling of the face, lips, or
IV (Children): Severe anaphylaxis 0.1 mg (less in younger children); may be eyelids). If condition occurs, withhold medication and notify health care profes-
followed by 0.1 mcg/kg/min continuous infusion (may bequp to 1.5 mcg/kg/min); sional immediately.
symptomatic bradycardia/pulseless arrest (PALS guidelines) 0.01 mg/kg, may Vasopressor: Monitor BP, pulse, ECG, and respiratory rate frequently during IV
be repeated q 3 5 min higher doses (up to 0.1 0.2 mg/kg) may be considered; may administration. Continuous ECG, hemodynamic parameters, and urine output
also be given by the intraosseous route. May also be given by the endotracheal route should be monitored continuously during IV administration.
in doses of 0.1 0.2 mg/kg diluted to a volume of 3 5 mL with normal saline fol- Monitor for chest pain, arrhythmias, heart rate 110 bpm, and hypertension.
lowed by several positive pressure ventilations. Consult physician for parameters of pulse, BP, and ECG changes for adjusting dose
Inhaln (Adults): Inhalation solution 1 inhalation of 1% solution; may be re- or discontinuing medication.
peated after 1 2 min; additional doses may be given q 3 hr; racepinephrine Via Shock: Assess volume status. Correct hypovolemia prior to administering epi-
hand nebulizer, 2 3 inhalations of 2.25% solution; may repeat in 5 min with 2 3 nephrine IV.
more inhalations, up to 4 6 times daily. Nasal Decongestant: Assess patient for nasal and sinus congestion prior to and
Inhaln (Children 1 mo): 0.25 0.5 mL of 2.25% racemic epinephrine solution periodically during therapy.
diluted in 3 mL normal saline. Lab Test Considerations: May cause transientpin serum potassium concen-
IV, Intratracheal (Neonates): 0.01 0.03 mg/kg q 3 5 min as needed. trations with nebulization or at higher than recommended doses.
IM (Children 1 mo 30 kg): 0.15 mg (EpiPen Jr); 30 kg: 0.3 mg (EpiPen). May cause anqin blood glucose and serum lactic acid concentrations.
Intracardiac (Adults): 0.3 0.5 mg. Toxicity and Overdose: Symptoms of overdose include persistent agitation,
Endotracheal (Adults): Cardiopulmonary resuscitation (ACLS guidelines) chest pain or discomfort, decreased BP, dizziness, hyperglycemia, hypokalemia,
2 2.5 mg. seizures, tachyarrhythmias, persistent trembling, and vomiting.
Topical (Adults and Children 6 yr): Nasal decongestant Apply 1% solution Treatment includes discontinuing adrenergic bronchodilator and other beta-ad-
as drops, spray, or with a swab. renergic agonists and symptomatic, supportive therapy. Cardioselective beta
Intraspinal (Adults and Children): 0.2 0.4 mL of 1:1000 solution. blockers are used cautiously because they may induce bronchospasm.
With Local Anesthetics (Adults and Children): Use 1:200,000 solution with local Potential Nursing Diagnoses
anesthetic. Ineffective airway clearance (Indications)
NURSING IMPLICATIONS Ineffective tissue perfusion (Indications)
Assessment Implementation
Bronchodilator: Assess lung sounds, respiratory pattern, pulse, and BP before Do not confuse epinephrine with ephedrine.
administration and during peak of medication. Note amount, color, and character High Alert: Patient harm or fatalities have occurred from medication errors with
of sputum produced, and notify health care professional of abnormal findings. epinephrine. Epinephrine is available in various concentrations, strengths, and
Monitor pulmonary function tests before and periodically during therapy. percentages and used for different purposes. Packaging labels may be easily con-
2015 F.A. Davis Company CONTINUED
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3 ban, ascorbic acid, atracurium, atropine, aztreonam, benztropine, bivalirudin,


bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium
PDF Page #3
gluconate, carboplatin, caspofungin, cefazolin, cefoperazone, cefotaxime, cefo-
CONTINUED tetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol , chlor-
EPINEPHrine promazine, cisatracurium, cisplatin, clindamycin, cyanocobalamin, cyclophos-
phamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone
fused or products incorrectly diluted. Dilutions should be prepared by a pharma- sodium phosphate, dexmedetomidine, dexrazoxane, digoxin, diltiazem, diphen-
cist. IV doses should be expressed in milligrams not ampules, concentration or hydramine, dobutamine, docetaxel, dopamine, doxorubicin, doxycycline, enala-
volume. Prior to administration, have second practitioner independently check prilat, ephedrine, epirubicin, epoetin alfa, eptifibatide, ertapenem, erythromycin,
original order, dose calculations, concentration, route of administration, and in- esmolol, etoposide, etoposide phosphate, famotidine, fenoldopam, fentanyl, flu-
fusion pump settings. conazole, fludarabine, folic acid, foscarnet, furosemide, gemcitabine, gentamicin,
Medication should be administered promptly at the onset of bronchospasm. glycopyrrolate, granisetron, heparin, hetastarch, hydrocortisone sodium succi-
Use a tuberculin syringe with a 26-gauge 12-in. needle for subcut injec- nate, hydromorphone, ibuprofen, idarubicin, ifosfamide, imipenem/cilastatin, ir-
tion to ensure that correct amount of medication is administered. inotecan, isoproterenol, ketamine, ketorolac, labetalol, levofloxacin, leucovorin
Tolerance may develop with prolonged or excessive use. Effectiveness may be re- caclium, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitol, mechlor-
stored by discontinuing for a few days and then readministering. ethamine, meperidine, metaraminol, methotrexate, methoxamine, methyldopa,
Do not use solutions that are pinkish or brownish or that contain a precipitate. methylprednisolone sodium succinate, metoclopramide, metoprolol, metronida-
For anaphylactic shock, volume replacement should be administered concur- zole, midazolam, milrinone, mitoxantrone, morphine, moxifloxacin, multiple vi-
rently with epinephrine. Antihistamines and corticosteroids may be used in con- tamins, mycophenolate, nafcillin, nalbuphine, naloxone, nicardipine, nitroglyc-
junction with epinephrine. erin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin,
IM, Subcut: Medication can cause irritation of tissue. Rotate injection sites to pre- oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pan-
vent tissue necrosis. Massage injection sites well after administration to enhance toprazole, pemetrexed, penicillin G potassium, pentamidine, pentazocine, phen-
absorption and to decrease local vasoconstriction. Avoid IM administration in glu- tolamine, phenylephrine, phytonadione, piperacillin/tazobactam, potassium ace-
teal muscle. tate, potassium chloride, procainamide, prochlorperazine, promethazine,
propofol, propranolol, protamine, pyridoxime, quinupristin/dalfopristin, raniti-
IV Administration dine, remifentanil, rocuronium, sodium acetate, streptokinase, succinylcholine,
Direct IV: Diluent: The 1:10,000 solution can be administered undiluted. Di- sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, ticarcillin/cla-
lute 1 mg (1 mL) of a 1:1000 solution in 9 mL of 0.9% NaCl to prepare a 1:10,000 vulanate, tigecycline, tirofiban, tobramycin, tolazoline, trimetaphan, vancomycin,
solution. Concentration: 0.1 mg/mL (1:10,000). Rate: Administer each 1 mg vasopressin, vecuronium, verapamil, vinblastine, vincristine, vinorelbine, vitamin
(10 mL) of a 1:10,000 solution over at least 1 min; more rapid administration B complex with C, voriconazole, warfarin, zoledronic acid.
may be used during cardiac resuscitation. Follow each dose with 20 mL IV saline Y-Site Incompatibility: acyclovir, alemtuzumab, aminophylline, azathioprine,
flush. carmustine, dantrolene, diazepam, diazoxide, fluorouracil, ganciclovir, indo-
Continuous Infusion: Diluent: Dilute 1 mg (1 mL) of a 1:1000 solution in 250 methacin, micafungin, pentobarbital, phenobarbital, phenytoin, sodium bicar-
mL of D5W or 0.9% NaCl. Protect from light. Infusion stable for 24 hr. Concen- bonate, thiopental, trimethoprim/sulfamethoxazole.
tration: 4 mcg/mL. Rate: See Route/Dosage section. Titrate to response (BP, Inhaln: When using epinephrine inhalation solution, 10 drops of 1% base solu-
heart rate, respiratory rate). tion should be placed in the reservoir of the nebulizer.
Y-Site Compatibility: alfentanil, amikacin, aminocaproic acid, amiodarone, The 2.25% inhalation solution of racepinephrine must be diluted for use in the
amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatro- combination nebulizer/respirator.
Canadian drug name. Genetic Implication. CAPITALS indicate life-threatening, underlines indicate most frequent. Strikethrough Discontinued.
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4 Advise patient to notify health care professional if pregnancy is planned or sus-


pected or if breast feeding.
Allow 1 2 min to elapse between inhalations of epinephrine inhalation solution Autoinjector: Instruct patients using auto-injector for anaphylactic reactions to PDF Page #4
to make certain the second inhalation is necessary. remove gray safety cap, placing black tip on thigh at right angle to leg. Press hard
When epinephrine is used concurrently with corticosteroid or ipratropium inha- into thigh until auto-injector functions, hold in place for 10 seconds, remove, and
lations, administer bronchodilator first and other medications 5 min apart to pre- discard properly. Massage injected area for 10 sec. Pedi: Teach parents or care-
vent toxicity from inhaled fluorocarbon propellants. givers signs and symptoms of anaphlyaxis, how to use auto-injector safely, and to
Endotracheal: Epinephrine can be injected directly into the bronchial tree via get the child to a hospital as soon as possible. Instruct parents or caregivers to
the endotracheal tube if the patient has been intubated. Perform 5 rapid insuffla- teach child how to manage his or her allergy, how to self-inject, and what to do in
tions; forcefully administer 10 mL containing 2 2.5 mg epinephrine (1 mg/mL) an emergency. For children too young to self-inject and who will be separated
directly into tube; follow with 5 quick insufflations. from parent, tell parents to always discuss allergy and use of auto-injector with re-
sponsible adult.
Patient/Family Teaching
Instruct patient to take medication exactly as directed. If on a scheduled dosing Evaluation/Desired Outcomes
regimen, take a missed dose as soon as possible; space remaining doses at regular Prevention or relief of bronchospasm.
intervals. Do not double doses. Caution patient not to exceed recommended dose; Increase in ease of breathing.
may cause adverse effects, paradoxical bronchospasm, or loss of effectiveness of Prevention of bronchospasm or reduction of frequency of acute asthma attacks in
medication. patients with chronic asthma.
Instruct patient to contact health care professional immediately if shortness of Prevention of exercise-induced asthma.
breath is not relieved by medication or is accompanied by diaphoresis, dizziness, Reversal of signs and symptoms of anaphylaxis.
palpitations, or chest pain. Increase in cardiac rate and output, when used in cardiac resuscitation.
Advise patient to consult health care professional before taking any OTC medica- Increase in BP, when used as a vasopressor.
tions or alcoholic beverages concurrently with this therapy. Caution patient also to Localization of local anesthetic.
avoid smoking and other respiratory irritants. Decrease in sinus and nasal congestion.
Inhaln: Review correct administration technique (aerosolization, IPPB) with pa-
tient. Why was this drug prescribed for your patient?
Do not spray inhaler near eyes.
Advise patients to use bronchodilator first if using other inhalation medications,
and allow 5 min to elapse before administering other inhalant medications, unless
otherwise directed.
Advise patient to rinse mouth with water after each inhalation dose to minimize dry
mouth.
Advise patient to maintain adequate fluid intake (2000 3000 mL/day) to help liq-
uefy tenacious secretions.
Advise patient to consult health care professional if respiratory symptoms are not
relieved or worsen after treatment or if chest pain, headache, severe dizziness,
palpitations, nervousness, or weakness occurs.
2015 F.A. Davis Company