EPINEPHRINE BITARTRATE IN 0.9% SODIUM CHLORIDE
Clinical safety rating
safeNo significant drug interactions Can cause hypernatremia and fluid overload.
Epinephrine is a direct-acting sympathomimetic amine that stimulates alpha- and beta-adrenergic receptors. Alpha-adrenergic effects increase peripheral vascular resistance and blood pressure. Beta1-adrenergic effects increase heart rate and contractility. Beta2-adrenergic effects cause bronchodilation and vasodilation in skeletal muscle.
| Metabolism | Epinephrine is metabolized primarily by catechol-O-methyltransferase (COMT) and monoamine oxidase (MAO) to metanephrine, normetanephrine, and other metabolites. Hepatic metabolism also occurs. |
| Excretion | Primarily renal; 90% as metabolites (metanephrine, vanillylmandelic acid) and unchanged drug; biliary/fecal <5%. |
| Half-life | Terminal elimination half-life: ~2 minutes following intravenous administration; clinical context: ultrashort duration necessitates continuous infusion or repeated boluses for sustained effect. |
| Protein binding | ~50% bound, primarily to albumin and alpha-1-acid glycoprotein. |
| Volume of Distribution | 0.3-0.5 L/kg; reflects distribution into highly perfused tissues and minimal plasma binding; clinical meaning: rapid distribution to target organs (heart, lungs, skeletal muscle). |
| Bioavailability | Intravenous: 100%; Subcutaneous: variable (20-40%) due to vasoconstriction; Intramuscular: 80-100% (deltoid site); Endotracheal: <10% (inconsistent). |
| Onset of Action | Intravenous: rapid (<1 minute); Endotracheal: 2-3 minutes; Intramuscular: 5-10 minutes; Subcutaneous: 5-15 minutes. |
| Duration of Action | Intravenous: 1-2 minutes; Subcutaneous/Intramuscular: 20-30 minutes; Clinical notes: duration is dose-dependent and limited by rapid metabolism; repeated dosing or infusion required for prolonged effect. |
| Molecular Weight | 333.29 |
Intravenous infusion: 0.1 to 1 mcg/kg/min, titrated to effect. Intravenous bolus: 1 mg every 3-5 minutes as needed for cardiac arrest. Intramuscular: 0.3 to 0.5 mg (1:1000 solution) for anaphylaxis, repeat every 5-15 minutes if necessary.
| Dosage form | SOLUTION |
| Renal impairment | No specific dose adjustment required for renal impairment. Use caution in patients with severe renal insufficiency due to potential for increased sensitivity. |
| Liver impairment | No specific dose adjustment required for hepatic impairment. Use caution in patients with severe hepatic insufficiency. |
| Pediatric use | Intravenous infusion: 0.1 to 1 mcg/kg/min, titrated to effect. Intravenous bolus: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) every 3-5 minutes for cardiac arrest. Intramuscular: 0.01 mg/kg (up to 0.3 mg) of 1:1000 solution for anaphylaxis. |
| Geriatric use | Initiate at lower end of dosing range (e.g., 0.1 mcg/kg/min IV infusion) and titrate slowly due to increased sensitivity and risk of adverse effects such as hypertension and tachycardia. Monitor closely. |
| 1st trimester | Limited human data; animal studies suggest increased risk of fetal hypoxia and decreased uterine blood flow. Use only if potential benefit outweighs risk. |
| 2nd trimester | May cause uterine vasoconstriction and reduced placental perfusion; use with caution for anaphylaxis or severe hypotension. |
| 3rd trimester | May delay labor due to inhibition of uterine contractions; use only for acute emergencies like anaphylaxis. |
Clinical note
No significant drug interactions Can cause hypernatremia and fluid overload.
| FDA category | Animal |
| Placental transfer | Epinephrine crosses the placenta; animal studies show transfer, but human data are limited. It is a catecholamine that can cause fetal effects. |
| Breastfeeding | Epinephrine is present in breast milk in very low quantities after parenteral administration; unlikely to affect the infant given its rapid metabolism and poor oral bioavailability. However, caution is advised with high systemic doses. |
| Lactation Rating | L2 (Probably Compatible) |
| Teratogenic Risk | FDA Pregnancy Category C. Epinephrine crosses the placenta. First trimester: Potential for teratogenicity based on animal studies (fetal hypoxia, malformations). Second and third trimesters: Uterine vasoconstriction may reduce placental perfusion, causing fetal hypoxia, bradycardia, or acidosis. High doses may delay labor due to β2-mediated tocolysis. |
| Fetal Monitoring | Continuous maternal heart rate, blood pressure, ECG, and oxygen saturation. Fetal heart rate monitoring (e.g., cardiotocography) for signs of distress. Monitor uterine activity for tocolysis or hyperstimulation. |
| Fertility Effects | Animal studies show no significant impairment of fertility. In humans, no well-controlled studies; theoretical risk of reduced uterine blood flow affecting implantation. |
■ FDA Black Box Warning
Epinephrine injection should not be used in patients with known hypersensitivity to sympathomimetic amines or any component of the product. Do not administer via the intravenous route unless diluted and under constant monitoring due to risk of cardiac arrhythmias and cerebral hemorrhage.
| Common Effects | fluid replacement |
| Serious Effects |
Hypersensitivity to epinephrine or any componentClosed-angle glaucomaCardiac arrhythmias (e.g., ventricular fibrillation)Coronary insufficiencyUse with halogenated hydrocarbon anesthetics (e.g., halothane) due to risk of sensitizing myocardium
| Precautions | May exacerbate angina, myocardial infarction, or cardiac arrhythmias, Use caution in patients with hypertension, hyperthyroidism, diabetes, or cerebrovascular disease, May cause transient increase in blood glucose, May worsen symptoms of prostate enlargement or obstructive uropathy, Rapid IV injection may cause cerebral hemorrhage due to severe hypertension |
| Food/Dietary | No known food interactions. Avoid excessive caffeine intake as it may potentiate the cardiovascular effects (tachycardia, hypertension). Maintain adequate hydration unless contraindicated. |
| Clinical Pearls | Epinephrine bitartrate in 0.9% sodium chloride is an isotonic solution appropriate for intravenous administration. The bitartrate salt does not alter pharmacodynamics compared to epinephrine hydrochloride. Use within 24 hours of preparation and protect from light. In cardiac arrest, administer as a 1 mg bolus every 3-5 minutes. For anaphylaxis, intramuscular injection in the anterolateral thigh is preferred over IV due to better safety profile; IV use reserved for profound shock or during resuscitation. Monitor for hypertension, tachyarrhythmias, and myocardial ischemia. Extravasation can cause tissue necrosis; treat with phentolamine. |
| Patient Advice | This medication is used for emergency treatment of severe allergic reactions or to restore heart rhythm during cardiac arrest. · Report any chest pain, rapid heartbeat, or difficulty breathing immediately. · May cause anxiety, tremors, or headache; these effects usually subside as the drug wears off. · Do not drive or operate machinery until you know how this medicine affects you. · Inform all healthcare providers that you have received epinephrine, as it may affect other treatments. · If you have high blood pressure, heart disease, diabetes, or thyroid problems, discuss with your doctor before use. · This solution contains salt; inform your doctor if you are on a low-sodium diet. |
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