Protocol for Administering Racemic Epinephrine in Croup
For treating croup, racemic epinephrine should be administered as a 2.25% inhalation solution at a dose of 0.05 mL/kg (maximum: 0.5 mL) in 2 mL of normal saline via nebulizer. 1 Many institutions standardize this to a 0.5 mL dose for all patients regardless of weight.
Dosing and Administration Details
Standard Dosing
- Concentration: 2.25% racemic epinephrine inhalation solution
- Dose calculation: 0.05 mL/kg up to maximum of 0.5 mL
- Diluent: Mix with 2 mL of normal saline
- Administration route: Nebulizer
- Standard institutional dose: Many facilities use a standard 0.5 mL dose for all patients 1
Alternative Option
If racemic epinephrine is unavailable, L-epinephrine (1:1000) can be substituted at a dose of 0.5 mL/kg up to a maximum of 5 mL 1, 2. Research shows L-epinephrine is at least as effective as racemic epinephrine with no additional adverse effects 2.
Monitoring and Follow-up Protocol
Post-Administration Monitoring
- Monitor for clinical improvement in stridor, respiratory rate, and work of breathing
- Peak effect occurs at approximately 10-30 minutes post-administration 3, 4
- Effect typically wanes by 2 hours post-administration 3, 4
- Monitor vital signs including heart rate, blood pressure, respiratory rate, and oxygen saturation
Observation Period
- Patients should be monitored for at least 2 hours after receiving racemic epinephrine 1
- This observation period is critical to determine if symptoms recur as the medication effect wanes
Repeat Dosing Considerations
Second Dose Protocol
- May repeat dose if symptoms recur or persist
- According to recent guidelines, patients who receive 2 or fewer doses of racemic epinephrine may be safely discharged if symptoms resolve 1
- Traditional practice often recommended admission after ≥2 doses, but recent evidence suggests this may not be necessary for all patients 5
Discharge Criteria After Multiple Doses
Patients can be safely discharged after multiple doses if:
- No stridor at rest persists after treatment
- Patient can tolerate oral fluids
- Oxygen saturation remains ≥92% on room air 6
- Patient appears clinically well without increased work of breathing 6
Admission Criteria
Consider hospital admission if any of the following are present:
- Oxygen saturation <92% or cyanosis
- Persistent significant respiratory distress after treatment
- Stridor at rest that persists after treatment
- Need for more than two doses of nebulized epinephrine
- Inability to tolerate oral fluids
- Toxic appearance 6
Important Clinical Considerations
Concurrent Medications
- Corticosteroids: Always administer dexamethasone (0.15-0.60 mg/kg) concurrently with racemic epinephrine for optimal treatment of croup 6
- Corticosteroids should be given even in mild cases to reduce inflammation and improve symptoms
Potential Adverse Effects
- Tachycardia
- Hypertension
- Pallor
- Tremor
- Vomiting
Contraindications
- Known hypersensitivity to epinephrine or any component of the formulation
- Use with caution in patients with cardiovascular disease
By following this protocol for racemic epinephrine administration in croup, clinicians can effectively manage symptoms while minimizing unnecessary hospitalizations. The evidence supports that many patients, especially those who become asymptomatic after treatment, can be safely managed as outpatients even after receiving multiple doses of racemic epinephrine 5.