Epinephrine, auto-injectors and anaphylaxis: challenges of dose, depth and device

Publication date: Available online 7 May 2018
Source:Annals of Allergy, Asthma & Immunology
Author(s): Julie Brown
Objectives1. To review epinephrine dosing, site and route of administration, focusing on special populations (patients weighing less that 15 kg, and obese patients). 2. To discuss storage and delivery of epinephrine in pre-hospital and hospital settings.Data SourcesReview of published literature.Study SelectionRelevancy.ResultsThe recommended 0.01 mg/kg (max 0.3-0.5 mg) epinephrine dose in anaphylaxis is based on limited pharmacokinetic data in healthy volunteers. There are no pharmacokinetic or pharmacodynamics studies involving patients in anaphylaxis. When epinephrine auto-injectors (EAIs) are used in infants, the dose increasingly exceeds the recommended dose as weight decreases, although the clinical significance is unclear. Limited data indicate that the intramuscular route and lateral thigh site are superior. Ultrasound studies suggest that 0.15 EAI needles may be too long for many patients under 15 kg and 0.3 mg EAI needles may be too short for obese patients over 30 kg. A newly available 0.1 mg EAI has a lower dose and shorter needle better suited to patients 7.5-15 kg. In some medical settings, vials and syringes may provide a safe, efficient alternative with substantial cost savings over EAIs.ConclusionEAIs should be available in the community with doses and needle depths that meet the needs of all patients. More research on epinephrine pharmacodynamics are needed in children and adults in anaphylaxis, in order to better delineate what optimal doses should be. Optimizing epinephrine dose and delivery has the potential to improve anaphylaxis outcomes and prevent adverse events.



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