Anaphylaxis Management with Epinephrine

Signs of Contamination and Preparation

The American Academy of Pediatrics recommends that epinephrine should be clear and colorless, as any discoloration, such as yellow, brown, or pink, indicates oxidation and degradation 1
The presence of particulate matter or a cloudy solution indicates microbial or chemical contamination, according to the American Academy of Pediatrics 1
The formation of crystals in the solution is also a sign of contamination, as stated by the American Academy of Pediatrics 1
In the event of contamination during the preparation of an intravenous epinephrine infusion for refractory anaphylaxis, the solution should be discarded and a new one prepared, with 1 mg (1 mL) of epinephrine 1:1000 added to 250 mL of D5W for a concentration of 4.0 mcg/mL, as recommended by the Journal of Allergy and Clinical Immunology 5

The American Academy of Pediatrics recommends administering 0.3-0.5 mg of epinephrine intramuscularly (IM) in the vastus lateralis of the thigh immediately in the event of anaphylaxis, with no delay in administration, as stated by the Pediatrics journal 2, 3
The dose of epinephrine should be repeated every 5 minutes as needed until resolution of symptoms, according to the Pediatrics journal and the Journal of Allergy and Clinical Immunology 2, 3, 4
There is no maximum number of doses of epinephrine IM for anaphylaxis, and 10-20% of patients require more than one dose, as stated by the Praxis Medical Insights and the Journal of Allergy and Clinical Immunology 3, 4

The Journal of Allergy and Clinical Immunology states that there is no absolute contraindication to epinephrine in anaphylaxis, even in elderly patients or those with cardiac disease, and that the benefits of epinephrine therapy outweigh the risks when administered in appropriate IM doses 4
The American Academy of Pediatrics recommends that epinephrine should be stored protected from light and in controlled room temperature, and that all ampules should be visually inspected before use, regardless of the expiration date 1
In situations of scarcity, expired epinephrine can be maintained as an emergency reserve if stored properly, as stated by the Pediatrics journal and the Journal of Allergy and Clinical Immunology 1, 5

If the patient does not respond to multiple IM doses, consideration should be given to transitioning to an intravenous epinephrine infusion, starting at 1-4 mcg/min and titrating up to a maximum of 10 mcg/min, as recommended by the Journal of Allergy and Clinical Immunology and the Praxis Medical Insights 3, 5
Continuous hemodynamic monitoring is required, and aggressive volume replacement with normal saline solution (1000-2000 mL in adults) should be administered, as stated by the Journal of Allergy and Clinical Immunology and the Praxis Medical Insights 3, 5