Post-Extubation Laryngeal Edema/Stridor (see Stridor)
Rationale
Results in local vasoconstriction, decreasing laryngeal edema
Clinical Efficacy
Efficacy is Unclear
Pediatric Trial of Dexamthasone and Nebulized Epinephrine in Laryngeal Edema (Int J Pediatr Otorhinolaryngol, 2009) [MEDLINE]: dexamethasone and L-epinephrine did not reduce the clinical progression of airway obstruction due to laryngeal edema in the early post-extubation period
Intramuscular (IM) (see Anaphylaxis): 0.3 mg (1:1,000 Dilution = 1 mg/mL) into anterior middle third of the thigh
Same Dose as Preloaded Epinephrine Injector Devices (EpiPen, Adrenaclick, Auvi-Q)
Intravenous (IV): recommended only for patients with refractory hypotension and lack of response to multiple intramuscular epinephrine injections or if patient is in cardiopulmonary arrest
Subcutaneous (SQ): no longer recommended (due to slower and less reliable absorption than intramuscular administration)
Post-Extubation Laryngeal Edema/Stridor (see Stridor)
Nebulized Racemic Epinephrine (Racepinephrine): 1 mL of 2.25% racepinephrine (contains 11.25 mg, as 13.5 of racepinephrine HCl)
Intrabronchial (Topical Instillation via Bronchoscope)
Dilute 10 mL of 1:10,000 Epinephrine (0.1 mg/mL) + 10 mL Normal Saline: yields 20 mL of 1:20,000 Epinephrine
Instill 2 mL Intrabronchially (Via Bronchoscope) at a Time (Max Total Dose: 10 mL = 0.5 mg)
Dose Adjustment
Hepatic: none
Renal: none
Extravasation Management
Epinephrine is a Vesicant: extravasation can cause tissue necrosis
Technique to Manage Extravasation
Discontinue Epinephrine Infusion and Gently Aspirate the Extravasated Solution
Phentolamine (see Phentolamine): dilute 5-10 mg in 10-15 mL of normal saline and administer into extravasation site as soon as possible after extravasation
Topical Nitroglycerin 2% Ointment (see Nitroglycerin): apply a 1 inch strip to the affected site
Drug Interactions
Spironolactone (Aldactone) (see Spironolactone): spironolactone may decrease the vasoconstrictor effect of α/β-adrenergic agonists
Inhalational Anesthetics: may increase the arrhythmogenic effect of epinephrine
MAO Inhibitors (see Monoamine Oxidase Inhibitors): may enhance the hypertensive effect of vasopressors (epinephrine, etc) and other sympathomimetics
Physiology: class effect (common to all catecholamines)
Increased Glycolysis and Pyruvate Production
Increased Lipolysis with Resultant Inhibition of Pyruvate Dehydrogenase: this prevents pyruvate from going through the Krebs cycle, resulting in pyruvate reduction to lactate
Adrenaline administered via a nebulizer in adult patients with upper airway obstruction. Anaesthesia. 1995;50:35–6 [MEDLINE]
The effect of epinephrine by nebulization on measures of airway obstruction in patients with acute severe croup. Intensive Care Med. 2008;34:138–47
L-epinephrine and dexamethasone in postextubation airway obstruction: a prospective, randomized, double-blind placebo-controlled study. Int J Pediatr Otorhinolaryngol. 2009;73:1639–43 [MEDLINE]
Nebulized epinephrine for croup in children. Cochrane Database Syst Rev. 2013;10:CD006619 [MEDLINE]
Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review. Crit Care. 2015 Sep 23;19:295. doi: 10.1186/s13054-015-1018-2 [MEDLINE]
