What are the other clinical uses of epinephrine (adrenaline) apart from anaphylaxis?

Clinical Uses of Epinephrine Beyond Anaphylaxis

Epinephrine is indicated for cardiac arrest (particularly non-shockable rhythms like PEA/asystole and shockable rhythms like VF/pVT after failed defibrillation), septic shock with hypotension, and induction/maintenance of mydriasis during intraocular surgery. 1, 2

Cardiac Arrest Management

The American Heart Association provides a Class 1 (strong) recommendation for epinephrine administration in cardiac arrest, with the standard dose being 1 mg IV/IO every 3-5 minutes during ongoing resuscitation. 1

Evidence for Cardiac Arrest Use

• Epinephrine significantly increases Return of Spontaneous Circulation (ROSC) rates, with 151 more patients per 1,000 achieving ROSC compared to placebo (RR 2.80,95% CI 1.78-4.41). 1
• It increases survival to hospital admission by 124 more patients per 1,000 (RR 1.95% CI 1.34-2.84). 1
• Meta-analyses demonstrate epinephrine significantly improves survival to discharge. 1

Timing Based on Rhythm

• For non-shockable rhythms (PEA/asystole): Administer epinephrine as soon as feasible (Class 2a recommendation). 1
• For shockable rhythms (VF/pVT): It may be reasonable to administer epinephrine after initial defibrillation attempts have failed (Class 2b recommendation). 1

Critical Dosing Considerations

• No maximum cumulative dose is defined in current guidelines, though cumulative doses above 3 mg may be associated with unfavorable neurological outcomes. 1
• High-dose epinephrine (0.1-0.2 mg/kg) is NOT recommended for routine use (Class 3: No Benefit). 1

Septic Shock Management

Epinephrine is indicated for hypotension associated with septic shock, though safety and effectiveness in pediatric patients with septic shock have not been established. 2

• Although epinephrine may improve maternal hypotension associated with septic shock, it may result in uterine vasoconstriction, decreased uterine blood flow, and fetal anoxia in pregnant patients. 2
• Avoid epinephrine in obstetrics when maternal blood pressure exceeds 130/80 mmHg. 2

Ophthalmic Surgery

Epinephrine (at a dilution of 1:100,000 to 1:400,000) is indicated for induction and maintenance of mydriasis during intraocular surgery in both adults and pediatric patients. 2

• The safety and effectiveness for this indication in pediatric patients is supported by adequate and well-controlled studies in adults and uncontrolled studies in pediatric patients. 2
• No overall differences have been observed between elderly and other patients for this indication. 2

Obstetric Considerations

In dosage sufficient to reduce uterine contractions, epinephrine may cause a prolonged period of uterine atony with hemorrhage. 2

• Despite these risks, epinephrine is the first-line medication of choice for treatment of anaphylaxis and should be used in the same manner for anaphylaxis in breastfeeding and non-breastfeeding patients. 2
• Due to its poor oral bioavailability and short half-life, epinephrine exposure is expected to be very low in the breastfed infant. 2

Common Pitfalls to Avoid

Delaying epinephrine administration in non-shockable cardiac rhythms is a critical error—it should be given as soon as feasible. 1

• The American Heart Association acknowledges a fundamental challenge in determining the likelihood of favorable versus unfavorable neurological outcome at the time of arrest. 1
• For elderly patients, consider starting with a lower dose to account for potential concomitant disease or other drug therapy, as geriatric patients may be particularly sensitive to the effects of epinephrine. 2