Can racemic epinephrine (adrenaline) worsen certain conditions in children?

Potential Adverse Effects of Racemic Epinephrine in Children

Racemic epinephrine can potentially worsen certain conditions in children, particularly cardiovascular conditions, and should be used with caution in specific patient populations. 1, 2

Cardiovascular Concerns

• Racemic epinephrine can cause increased heart rate, myocardial irritability, and increased oxygen demand, which may worsen underlying cardiovascular conditions 1
• There are documented cases of myocardial infarction following racemic epinephrine administration in pediatric patients with croup, even with normal coronary anatomy 2
• Severe overdose can lead to significant cardiovascular complications requiring intensive care, including hypertensive crisis followed by hypotension due to adrenergic receptor down-regulation 3

Specific Conditions Where Caution Is Needed

• Children with underlying heart disease may experience adverse effects from racemic epinephrine due to its cardiovascular stimulant properties 4
• Patients with high blood pressure may experience dangerous elevations in blood pressure that could increase risk of stroke or heart attack 4
• Children with diabetes, thyroid disease, or seizure disorders require careful monitoring when receiving racemic epinephrine 4
• Patients with narrow-angle glaucoma may experience worsening of their condition 4

Dosing and Administration Concerns

• The American Academy of Pediatrics recommends a standard dosing of 0.05 mL/kg of 2.25% solution (maximum: 0.5 mL) in 2 mL of normal saline administered by nebulizer for croup treatment 1
• Using incorrect concentrations of epinephrine can lead to potentially fatal overdose, particularly when 1:1000 solution is incorrectly administered intravenously instead of the appropriate 1:10000 solution 5
• Multiple doses of racemic epinephrine may be needed in some children, particularly those who have recently received steroids prior to presentation 6

Monitoring and Safety Considerations

• Patients who receive racemic epinephrine for croup should be observed for 2-3 hours after administration to monitor for symptom rebound 1
• Children with recent use of steroids prior to emergency department presentation have a greater need for multiple doses of racemic epinephrine during hospitalization 6
• Racemic epinephrine should not be used in the home setting due to its short duration of action and potential adverse effects 1

Drug Interactions

• Racemic epinephrine should not be used in patients taking monoamine oxidase inhibitors (MAOIs) or within 2 weeks of stopping MAOI therapy 4
• Caution is needed when using racemic epinephrine in patients taking medications for asthma, obesity, weight control, depression, or psychiatric conditions 4
• Concurrent use with other medications containing phenylephrine, pseudoephedrine, ephedrine, or caffeine may increase risk of adverse effects 4

Clinical Decision-Making Algorithm

1. Assess for contraindications:

   • Heart disease
   • High blood pressure
   • Diabetes
   • Thyroid disease
   • Seizure disorders
   • Narrow-angle glaucoma
   • MAOI use

2. If no contraindications, administer appropriate dose based on weight and condition

   • For croup: 0.05 mL/kg of 2.25% solution (maximum: 0.5 mL) in 2 mL normal saline via nebulizer 1

3. Monitor closely for:

   • Tachycardia
   • Hypertension
   • Tremors
   • Pallor
   • Cardiac arrhythmias

4. Observe for at least 2-3 hours after administration to monitor for symptom rebound 1

5. Consider hospitalization if multiple doses are required, particularly in younger children or those with higher initial croup scores 7

Despite these concerns, when used appropriately at correct dosages with proper monitoring, racemic epinephrine remains an effective treatment for conditions like croup in children 8.