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Drug dosage identifier

Adrenaline Hydrochloride

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Dose and administration

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IV push

0.1-0.3 ml/kg 1:10,000 concentration by IV push, or intracardiac.

Intratracheal

0.3ml/kg 1:10,000 concentration. Repeat dose every 3-5 minutes as necessary.

Continuous infusion

  1. 100-300 nanograms/kg/minute (0.1-0.3micrograms/kg/minute). Start at 100 nanograms/kg/minute (0.1micrograms/kg/minute) and titrate to desired response to a maximum of 1000 nanograms/kg/minute (1microgram/kg/minute).
  2. Use 1:10,000 concentration (0.1mg/ml) to prepare continuous infusion. 
  3. Usual dilution 0.3 mg/kg in 50ml D5W, D10W, NS. 
Use as a continuous infusion should be discussed with specialist on call.  Give through a Central Venous Line (UVC, Longline, or Surgical CVL)

Slow IV push/intracardiac

0.1-0.3ml/kg/minute, 1:10,000 concentration.

Indications

  1. Acute cardiovascular collapse (bradycardia, asystole).
  2. Can be used as a second or third line inotrope.
  3. Short-term use for cardiac failure resistant to other drug management.

Contraindications and precautions

  1. Hypersensitivity to sympathomimetics.
  2. Shock.
  3. Caution in infants with cardiovascular disease, hypertension.

Clinical pharmacology

Adrenaline, a catecholamine, stimulates alpha and beta receptors. It increases heart rate, increases myocardial contractility, automaticity and conduction velocity. Adrenaline also increases systemic vascular resistance (via constriction of arterioles), and increases blood flow to skeletal muscle, brain, liver and myocardium. It decreases renal blood flow by 40%. Pulmonary resistance may increase, although the major effect of adrenaline is to redistribute blood from the systemic to pulmonary circulation and thereby increase pulmonary pressure.

Adrenaline must be given parenterally to reach pharmacologically effective concentrations because it is rapidly metabolised in the gastrointestinal tract and liver. Its vasoconstrictive properties account for the slow rate of absorption from subcutaneous or intramuscular administration sites. The major portion of adrenaline is rapidly metabolised by the same enzyme systems that metabolise endogenous catecholamines.

Possible adverse effects

  1. Venous irritation, soft tissue injury at the site of IV infusion.
  2. Cardiac arrhythmias (PVCs and ventricular tachycardia).
  3. Renal vascular ischaemia with decreased urine formation.
  4. Severe hypertension with intracranial haemorrhage.
  5. Pulmonary oedema.
  6. Hyperglycaemia related to the inhibition of insulin secretion and conversion of glycogen reserves.
  7. Hypokalaemia.

Special considerations

  1. Always use as a 1:10,000 concentration (0.1 mg/ml) for individual doses.
  2. If possible, correct acidosis before administration of adrenaline to enhance the effectiveness of the drug.

Management of adrenaline administration

Prescription

Slow intravenous push, intratracheal and intracardiac adrenaline are charted on the stat page of the drug prescription chart in ml/dose.

Continuous infusions

Charted on fluid chart giving:

  • rate in ml/hour
  • dose in nanograms/kg/minute

Also charted on drug chart under continuous infusions giving:

  • amount of drug to be added
  • base fluid, type and volume

Administration

Administration of intratracheal adrenaline for resuscitation
Administered by doctor / NS-ANP or a nurse with Neonatal IV Drug Certification.
Dilute in 1-2ml of NS.
Instil into endotracheal tube. May be repeated as necessary.
Continuous infusion (use 1:10,000 strength adrenaline)
Administered by a nurse with Neonatal IV Drug Certification.
Dilute prior to administration.
Do NOT use discoloured solutions.
Filter prior to administration through a Pall 0.2 micron filter.
Compatible with D5W, D10W and NS. Incompatible with alkaline solutions/drugs.
Do NOT mix with other drugs, blood or blood products.
Protect from light during administration. Wrap tubing in tinfoil and cover syringe.
Administer via a syringe pump.
Give through a central venous line (UVC, Longline, or Surgical CVL).
Slow intravenous push
Is administered by the doctor / NS-ANP. In an emergency situation the nurse may administer under the direct supervision of the doctor / NS-ANP present.
Further dilution is not necessary. Do not use discoloured solutions.
Administer IV by slow push over 5 minutes.
Filter prior to administration through a Pall 0.2 micron filter.
Compatible with NS, D5W and D10W. Incompatible with alkaline solutions/drugs.
Do NOT mix with other drugs,IV solutions, blood or blood products.
Flush with NS before and after administration of adrenaline.
Administration of intracardiac adrenaline
This is a medical staff only procedure.
To be administered with a 22 gauge needle.

Nursing considerations

  1. Observe IV site for signs of infiltration.
  2. Continuous blood pressure monitoring or 5 minute BP recordings.
  3. Continuous cardiorespiratory monitoring.
  4. Document vital signs hourly and PRN.
  5. Assess need for endotracheal suctioning. Mucous plugs may become more difficult to dislodge.

Storage

  • At room temperature.
  • Protect from light.
  • Discard ampoule after opening.
  • Continuous infusions. No stability data available for dilute solutions of adrenaline. Change solutions 8 hourly or more frequently if BP not maintained.

References

  1. Guys, Lewisham and St Thomas Hospitals, Paediatric Formulary, 3rd Edition 1993, p11.
  2. Royal Children's Hospital, Melbourne. Paediatric Pharmacopaeia 11th Edition 1994, p5.

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Document Control

  • Date last published: 30 November 2011
  • Document type: Drug Dosage Guideline
  • Services responsible: Neonatology, ADHB Pharmacy
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years