Epinephrine

2 ) : o Dilute epinephrine in dextrose solution prior to infusion. o Infuse epinephrine into a large vein. 05 mcg/kg/min to 2 mcg/kg/min to achieve desired blood pressure. o Wean gradually. 1 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. 2 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. 05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP). 2 mcg/kg/min, to achieve the desired blood pressure goal.

After hemodynamic stabilization, wean incrementally over time, such as by decreasing doses of epinephrine every 30 minutes over a 12- to 24-hour period.

6)] The following adverse reactions associated with the infusion of epinephrine were identified in the literature. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency reliably or to establish a causal relationship to drug exposure.

Cardiovascular disorders: tachycardia, supraventricular tachycardia, ventricular arrhythmias, myocardial ischemia, myocardial infarction, limb ischemia, pulmonary edema Gastrointestinal disorders : Nausea, vomiting General disorders and administrative site conditions : Chest pain, extravasation Metabolic : hypoglycemia, hyperglycemia, insulin resistance, hypokalemia, lactic acidosis Nervous system disorders : Headache, nervousness, paresthesia, tremor, stroke, central nervous system bleeding Psychiatric disorders : Excitability Renal disorders : Renal insufficiency Respiratory : Pulmonary edema, rales Skin and subcutaneous tissue disorders : Diaphoresis, pallor, piloerection, skin blanching, skin necrosis with extravasation Most common adverse reactions to systemically administered epinephrine are headache; anxiety; apprehensiveness; restlessness; tremor; weakness; dizziness; sweating; palpitations; pallor; peripheral coldness; nausea/vomiting; and/or respiratory difficulties.

Arrhythmias, including fatal ventricular fibrillation, rapid rises in blood pressure producing cerebral hemorrhage, and angina have occurred. 1) To report SUSPECTED ADVERSE REACTIONS, contact Amphastar Pharmaceuticals, Inc. gov/medwatch.

5 WARNINGS AND PRECAUTIONS • Monitor blood pressure frequently. 1) • Increases cardiac output and causes peripheral vasoconstriction. 2) • May induce cardiac arrhythmias and myocardial ischemia. 3) • Avoid extravasation into tissues, which can cause local necrosis.

4) • Constricts renal blood vessels which may result in oliguria or renal impairment. 5) • Sulfite Warning. 1 Hypertension Because individual response to epinephrine may vary significantly, monitor blood pressure frequently and titrate to avoid excessive increases in blood pressure.

Patients receiving monoamine oxidase inhibitors (MAOI) or antidepressants of triptyline or imipramine types may experience severe, prolonged hypertension when given epinephrine. 2 Pulmonary Edema Epinephrine increases cardiac output and causes peripheral vasoconstriction, which may result in pulmonary edema.

3)] . 4 Extravasation and Tissue Necrosis with Intravenous Infusion Avoid extravasation of epinephrine into the tissues, to prevent local necrosis. When Epinephrine Injection is administered intravenously, check the infusion site frequently for free flow.

Blanching along the course of the infused vein, sometimes without obvious extravasation, may be attributed to vasa vasorum constriction with increased permeability of the vein wall, permitting some leakage. This also may progress on rare occasions to superficial slough.

Hence, if blanching occurs, consider changing the infusion site at intervals to allow the effects of local vasoconstriction to subside. There is a potential for gangrene in a lower extremity when infusions of catecholamine are given in an ankle vein.

Antidote for Extravasation Ischemia:

To prevent sloughing and necrosis in areas in which extravasation has taken place, infiltrate the area with 10 mL to 15 mL of saline solution containing from 5 mg to 10 mg of phentolamine, an adrenergic blocking agent. Use a syringe with a fine hypodermic needle, with the solution being infiltrated liberally throughout the area, which is easily identified by its cold, hard, and pallid appearance.

4 CONTRAINDICATIONS None. None.