Epinephrine and phenylephrine previ...

Epinephrine and phenylephrine previously have been identified as high-alert medications, a designation that springs from the narrow margin of safety associated with their use. (1) The Joint Commission in succession Accreditation of Healthcare Organizations (JCAHO), AORN, the United States Pharmacopeia (USP), and the Institute for Safe Medication Practices all have received reports of adverse consequences involving epinephrine and phenylephrine in the OR and other surgical settings. These adverse incidents most frequently were related to solutions being diluted incorrectly or the evil concentration being used.

A case involving mislabeled epinephrine 1:1000 that consequence ed in the death of a seven-year-old child in a Florida OR was reported widely in the one and the other the professional and consumer media. The Joint Commission has received sentinel end reports for occurrences in the OR in which side powers from nasally applied phenylephrine issueed in death, as well as reports in which the use of epinephrine in the OR followed in adverse events or death. The USP, by means of its Medmarx medication error reporting program, has received multiple reports of epinephrine medication errors in the OR. single in kind resulted in a patient's death, another in cardiac arrest, and several others placed patients at risk of injury. None of the adverse conclusions reported to Medmarx also were reported to JCAHO. Medmarx also contains medication error reports of multiple mishaps with epinephrine in day surgery settings and postanesthesia care units.

In addition to the errors reported to Medmarx and JCAHO, there are a number of documented cases of intraoperative cardiac complications resulting from the use of individual of these medications, alone or in combination with other medications (eg cocaine), during otorhinolaryngologic processs (2) Other case reports (n = 12) of plain hypertension have been documented after the intraoperative use of topical phenylephrine, submucosal epinephrine, or the one and the other during nasal surgery, for intubation intents or when injected into the submucosal area of the palate. (3) Epinephrine when combined with cocaine during septoplasty also has been associated with myocardial ischemia in unsuspected coronary artery disease. (4)

WHAT IS EPINEPHRINE?

Epinephrine (ie, adrenaline) stimulates alpha, beta-one, and beta-two sympathetic effector small cavitys in a dose-related fashion. Its in the greatest degree prominent actions are on the beta receptors of the heart, vascular muscles, and other even muscles (Table 1). The dose, hardness and concentration of epinephrine all are related closely to the intention of its use and a patient's general condition and age. (5)

Epinephrine is supplied and used in various concentrations (Table 2) Clinicians handling and administering epinephrine must verify the pair the dose form and concentration. Clinicians ne to understand that 1:1000 is the mostly concentrated form of epinephrine when compared to 1:100000 or 1:200000 which are abundant less concentrated forms of the medication in solution. Epinephrine can be used for a variety of intentions in the perioperative setting, including

* relieving bronchospasm,

* treating sensitivity reactions,

* restoring cardiac harmonious flow during cardiac arrest,

* treating cardiac arrhythmias,

* prolonging action of local and regional anesthetics,

* providing local vasoconstriction,

* reducing conjunctival congestion, or

* treating mucosal congestion.

Bronchospasm or hypersensitivity reactions. For rigid anaphylaxis or asthma, the usual initial dose is 01 mg to 05 mg (ie, 01 mL to 05 mL of a 1:1000 injection) given subcutaneously or intramuscularly. If given via the intramuscular (IM) way the buttocks should be avoided.

Cardiac arrest and cardiac arrhythmia. During cardiopulmonary resuscitation and when treating certain cardiac arrhythmias, epinephrine generally is administered on IV, but it also can be instilled directly into the tracheobronchial tree via an endotracheal tube, intraosseous infusion, or intracardiac injection. During cardiopulmonary resuscitation, the usual adult dose is 05 mg to 1 mg (ie, usually as 5 mL to 10 mL of a dose of a 1:10000 injection). (6)

Anesthesia and local vasoconstriction. united common use of epinephrine in the OR involves its topical administration via cotton or gauze to mucous membranes or other tissues. In this instance, concentrations used can vary from 1:1000 to 1:50000 In combination with local anesthetics, epinephrine may be used in concentrations of 1:50000 to 1:500000 The in the greatest degree frequently used concentration in local anesthetics is 1:200000 (7) When used for intranasal proceedings there may be unpredictable medication absorption. (8)

For vasoconstriction, epinephrine repeatedly is diluted with varying amounts of normal saline or other solution for use as an irrigating solution. For example, a solution for a hip or shoulder arthroscopy may consist of epinephrine 1 mg (ie, 1 mL of a 1:1000 solution) in 3 L of normal saline. Tumescent solution, which is used during plastic surgery may include epinephrine 1 mg (ie, 1 mL of a 1:1000 solution) in 1000 mL of normal saline along with 500 mg or 1000 mg of lidocaine and 125 mEq of sodium bicarbonate. (9)