Patient safety first alert—epinephrine and phenylephrine in surgical settings

AORN Journal,  April, 2003  by Suzanne C. Beyea,  Rodney W. Hicks

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Epinephrine and phenylephrine previously have been identified as high-alert medications, a designation that results from the narrow margin of safety associated with their use. (1) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), AORN, the United States Pharmacopeia (USP), and the Institute for Safe Medication Practices all have received reports of adverse events involving epinephrine and phenylephrine in the OR and other surgical settings. These adverse events most frequently were related to solutions being diluted incorrectly or the wrong concentration being used.

A case involving mislabeled epinephrine 1:1,000 that resulted in the death of a seven-year-old child in a Florida OR was reported widely in both the professional and consumer media. The Joint Commission has received sentinel event reports for occurrences in the OR in which side effects from nasally applied phenylephrine resulted in death, as well as reports in which the use of epinephrine in the OR resulted in adverse events or death. The USP, through its Medmarx medication error reporting program, has received multiple reports of epinephrine medication errors in the OR. One resulted in a patient's death, another in cardiac arrest, and several others placed patients at risk of injury. None of the adverse events reported to Medmarx also were reported to JCAHO. Medmarx also contains medication error reports of multiple mishaps with epinephrine in day surgery settings and postanesthesia care units.

In addition to the errors reported to Medmarx and JCAHO, there are a number of documented cases of intraoperative cardiac complications resulting from the use of one of these medications, alone or in combination with other medications (eg, cocaine), during otorhinolaryngologic procedures. (2) Other case reports (n = 12) of severe hypertension have been documented after the intraoperative use of topical phenylephrine, submucosal epinephrine, or both during nasal surgery, for intubation purposes, or when injected into the submucosal area of the palate. (3) Epinephrine when combined with cocaine during septoplasty also has been associated with myocardial ischemia in unsuspected coronary artery disease. (4)

WHAT IS EPINEPHRINE?

Epinephrine (ie, adrenaline) stimulates alpha, beta-one, and beta-two sympathetic effector cells in a dose-related fashion. Its most prominent actions are on the beta receptors of the heart, vascular muscles, and other smooth muscles (Table 1). The dose, strength, and concentration of epinephrine all are related closely to the purpose of its use and a patient's general condition and age. (5)

Epinephrine is supplied and used in various concentrations (Table 2). Clinicians handling and administering epinephrine must verify both the dose form and concentration. Clinicians need to understand that 1:1,000 is the most concentrated form of epinephrine when compared to 1:100,000 or 1:200,000, which are much less concentrated forms of the medication in solution. Epinephrine can be used for a variety of purposes in the perioperative setting, including

* relieving bronchospasm,

* treating sensitivity reactions,

* restoring cardiac rhythm during cardiac arrest,

* treating cardiac arrhythmias,

* prolonging action of local and regional anesthetics,

* providing local vasoconstriction,

* reducing conjunctival congestion, or

* treating mucosal congestion.

Bronchospasm or hypersensitivity reactions. For severe anaphylaxis or asthma, the usual initial dose is 0.1 mg to 0.5 mg (ie, 0.1 mL to 0.5 mL of a 1:1,000 injection) given subcutaneously or intramuscularly. If given via the intramuscular (IM) route, the buttocks should be avoided.

Cardiac arrest and cardiac arrhythmia. During cardiopulmonary resuscitation and when treating certain cardiac arrhythmias, epinephrine generally is administered by IV, but it also can be instilled directly into the tracheobronchial tree via an endotracheal tube, intraosseous infusion, or intracardiac injection. During cardiopulmonary resuscitation, the usual adult dose is 0.5 mg to 1 mg (ie, usually as 5 mL to 10 mL of a dose of a 1:10,000 injection). (6)

Anesthesia and local vasoconstriction. One common use of epinephrine in the OR involves its topical administration via cotton or gauze to mucous membranes or other tissues. In this instance, concentrations used can vary from 1:1,000 to 1:50,000. In combination with local anesthetics, epinephrine may be used in concentrations of 1:50,000 to 1:500,000. The most frequently used concentration in local anesthetics is 1:200,000. (7) When used for intranasal procedures, there may be unpredictable medication absorption. (8)

For vasoconstriction, epinephrine often is diluted with varying amounts of normal saline or other solution for use as an irrigating solution. For example, a solution for a hip or shoulder arthroscopy may consist of epinephrine 1 mg (ie, 1 mL of a 1:1,000 solution) in 3 L of normal saline. Tumescent solution, which is used during plastic surgery, may include epinephrine 1 mg (ie, 1 mL of a 1:1,000 solution) in 1,000 mL of normal saline along with 500 mg or 1,000 mg of lidocaine and 12.5 mEq of sodium bicarbonate. (9)