From the Guidelines
Racemic epinephrine is indicated for croup in cases where nebulised adrenaline is required to avoid intubation, stabilize children prior to transfer to intensive care, or in stridor following intubation, as stated in the British Thoracic Society guidelines 1.
Key Points to Consider
- The effect of racemic epinephrine, or nebulised adrenaline, is short-lived, lasting 1–2 hours, which necessitates close monitoring and potential repeated administration 1.
- It should not be used in children who are shortly to be discharged or on an outpatient basis due to its short duration of action and the need for observation 1.
- The use of racemic epinephrine as a rescue therapy aims to reduce subglottic edema through vasoconstriction of the airway mucosa, temporarily improving airflow.
- Recent studies, such as the one published in Pediatrics in 2022 1, focus on reducing hospital admissions for croup through clinical guidelines and ordersets, but do not directly address the indications for racemic epinephrine.
Administration and Monitoring
- Racemic epinephrine should be administered as a nebulized solution, typically in an emergency department or inpatient setting, where close monitoring is possible.
- The administration should be alongside corticosteroids, which provide longer-lasting anti-inflammatory effects, as part of a comprehensive treatment plan for croup.
- Observation for at least 2-3 hours after administration is crucial to monitor for rebound symptoms, given the short-lived effects of racemic epinephrine.
From the Research
Indications for Racemic Epinephrine in Croup
- Racemic epinephrine is indicated for moderate to severe croup, particularly when there is a need for rapid relief of symptoms such as stridor and respiratory distress 2, 3.
- The use of racemic epinephrine may be considered in conjunction with corticosteroids like dexamethasone, as the benefits of corticosteroids may be delayed 4, 3.
- Racemic epinephrine can provide short-term improvement in croup symptoms, but its effects may be transient, and repeated doses may be necessary 2.
Comparison with Other Treatments
- Heliox, a mixture of helium and oxygen, may be beneficial in the short term for children with moderate croup treated with dexamethasone, with effects similar to 100% oxygen given with one or two doses of adrenaline 4, 5, 6.
- The choice between racemic epinephrine and other treatments like heliox may depend on the severity of croup, the availability of treatments, and the clinical judgment of the healthcare provider 4, 2, 5, 6.
Important Considerations
- The use of racemic epinephrine should be carefully considered due to potential dose-related adverse effects, including tachycardia, arrhythmias, and hypertension 4, 2.
- Close monitoring of patients receiving racemic epinephrine is essential to minimize the risk of adverse effects and to assess the need for repeated doses or alternative treatments 2.