Epinephrine in a code racemic or L isomer?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
ttac

ttac

Trust me, it's still fun.
15+ Year Member
20+ Year Member
Joined
Dec 11, 2001
Messages
671
Reaction score
2
This is sort of a cross-post from the Allo forum since I'm hoping that ER docs might be more able to answer this question than med students:

We're having this debate about epinephrine used in codes. I've seen an article referring to it as the L-isomer. I know that the body synthesizes L-epi and uses it exclusively instead of a racemic mixture. However, nobody ever refers to it as "racemic epi", which to me means that it must be either L-epi or D-epi, (likely L-epi). Does anybody know which one it is? Also if it IS L-epi, has there been any study comparing racemic epi and L-epi in codes? In croup they have been shown to be equivalent.

Finally, if code epi is also racemic, then why are we calling croup epi "racemic epi", and code epi "epi" ?

According to this article, L-epi is just as good as the racemic epi used in croup. And it's cheaper. This really boggles my mind... I assumed that the synthesis of epi was not stereospecific and you had to purify the L-isomer out. So how in the heck is a pure stereoisomer cheaper than the racemic mixture? HUH?
(http://www.sparknotes.com/chemistry/organic3/stereoisomers/section2.rhtml)


Pediatrics. 1992 Feb;89(2):302-6. Links
Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup).Waisman Y, Klein BL, Boenning DA, Young GM, Chamberlain JM, O'Donnell R, Ochsenschlager DW.
Emergency Medical Trauma Center, Children's National Medical Center, Washington, DC.

Aerosolized racemic epinephrine, but not L-epinephrine, is commonly used in treating croup. The efficacy and adverse effects of nebulized racemic and L-epinephrine in the treatment of laryngotracheitis were compared. Children 6 months to 6 years of age with a croup score of 6 or above were assigned in a randomized double-blind fashion to receive either racemic (n = 16) or L-epinephrine (n = 15) aerosols. Croup score, heart rate, blood pressure, respiratory rate, fraction of inspired oxygen, and oxygen saturation were recorded before treatment and at 5, 15, 30, 60, 90, and 120 minutes after the aerosol. Patients in both groups showed significant transient reduction of the croup score and respiratory rate following the aerosol (P less than .001), but there were no differences between treatment groups when croup score, heart rate, blood pressure, and respiratory rate were assessed over time. It is concluded that L-epinephrine is at least as effective as racemic epinephrine in the treatment of laryngotracheitis and does not carry the risk of additional adverse effects. L-Epinephrine is also more readily available worldwide, is less expensive, and can be recommended for this purpose.

Sorry for rambling...
ttac
Members don't see this ad.
 
i'll go ahead and field this one for the entire EM subforum...

who the **** gives a ****?!

/that'll do boys
 
Um... let's say that a patient is coding in front of you (PEA) and you don't have the crash cart... but you have a ton of racemic from just treating the kid with croup... Do you use the racemic epi or not?

ttac
 
Members don't see this ad :)
ttac said:
Um... let's say that a patient is coding in front of you (PEA) and you don't have the crash cart... but you have a ton of racemic from just treating the kid with croup... Do you use the racemic epi or not?

ttac
Click to expand...
no, you go and get the crash cart. unles you're going to treat the code patient with aerosolized epi :laugh: :scared: :rolleyes:
 
EC3 said:
no, you go and get the crash cart. unles you're going to treat the code patient with aerosolized epi :laugh: :scared: :rolleyes:
Click to expand...

hehe... just because it _can_ be aerosolized doesn't mean it _has_ to be... you just draw out the epi with a syringe (should be 5mL of 1:1000)...
 
From what I've tried to look up, the only ways that the L-isomer is cheaper are that the process involves purifying the compound from living critters, and thus they are able to make more of it, thus lessening the price. Either that, or they are using bacteria to make it (like insulin), and that is pretty much the same. Because if they were sythesizing it from just carbon molecules, then the racemic mixture would be much cheaper.
 
And you can give epi through the ET tube if you don't have access.
 
sure... but like 10X more or so right? I forget the actual amount.
 
ttac said:
hehe... just because it _can_ be aerosolized doesn't mean it _has_ to be... you just draw out the epi with a syringe (should be 5mL of 1:1000)...
Click to expand...

No! That would be 50 X the epi used in cardiac arrest. Any epi given intravenously is a 1:10,000 solution!

Let's take a step back, since many of you are focusing on the wrong things, and have many of your facts mixed up. First of all, there is a big difference between Inhaled Epinephrine, Racemic Epinephrine, Intravenous Epinephrine, and SC Epinephrine. You should not interchange them. Do not substitue one for the other.

Racemic Epi -(MicroNephrin) - comes in a 2.25% Neb solution and 0.5cc Neb can be given every 3 hrs
Inhaled Epi - comes in a 10mg/cc neb solution and 0.5cc Neb can be given every 3 hours

These formulations should NOT be given Intravenously. Epinephrine which is needed systemically can be administered either IV, IM, SC, Intracardiac, or Endotracheally.

IV Epi - given in cardiac arrest, or impending anaphylactic cardiac collapse. The dose is 1mg and it needs to be a 1:10,000 solution.

Alternatives are Intracardiac Epi or Endotracheal Epi - both are also 1 mg doses and given with 1:10,000 solution. Some advocate an increased endotracheal dose of 3 or 5mg instead of 1mg.

IM/SC Epi - given in anaphylaxis, or severe asthma. The dose is 0.3 mg and it needs to be a 1:1,000 solution. This dose may be repeated if necessary.

In a code... establish the airway by BVM, start CPR... call someone else to get the crash cart with the epi... A,B,C's first.
 
Thanks waterski for answering ttac's question. We always joke about questions like this because we are intimately familiar with epi because we are emergency physicians. However, for many people, the answers are less clear. We should have more compassion for people asking questions like this. What if we asked a cardiologist to help us interpret a subtle finding of an EKG and he/she treats us like this because in his specialty, questions like this are unheard of because they are so simplistic.
 
leviathan said:
2 to 2.5 times as much for any ET drugs.
Click to expand...

waterski232002 said:
Some advocate an increased endotracheal dose of 3 or 5mg instead of 1mg...
Click to expand...

In PALS they recommend for epinephrine using 10x the dose if given endotracheal. They base it off of animal models. All the other endotracheal meds they still recommend 2-3x the dose. In the ACLS manual, it doesnt discriminate between epi, lido, atropine or naloxone, all are given 2-3x the dose if through the ETT.
 
New ACLS guidlines do not recomend giving any drugs through the ET tube.
 
Members don't see this ad :)
My understanding is that giving drugs thru the ETT should only be done if IV access cant be obtained and is favorable over IM because of the slow uptake of IM meds.
 
leviathan said:
What is the reasoning for that??? What do you if their veins are collapsed and you need to give epi, or if you have an OD with sclerosed veins and they need naloxone?
Click to expand...

Have you ever seen epi given ET? Not to be crass but I've seen this done a lot and it's generally not pretty. Very poor absorption in a code. From what I've seen, after a few doses you are ventilating through an epi/lidocaine/atropine soup. Additionally, I think the slim (to zero) benefit of these drugs in a cardiac arrest may not worth the possible complications.

Narcan, can be given SQ, IM or IV. Also, they're generally not very happy when they wake up intubated.;)
 
My understanding is that absorption of drugs is nil, delayed, or reduced to the point of not being useful in resucitation. Don't forget you can always put in an IO regardless of what kind of veins they have.

If I had no IV access and no IO, I guess I would consider it. It has never made much sense to me to put a bunch of liquid down someone's ET tube that you are trying to oxygenate.
 
leviathan said:
What is the reasoning for that??? What do you if their veins are collapsed and you need to give epi, or if you have an OD with sclerosed veins and they need naloxone?
Click to expand...

If Narcan is needed and there is no IV, inject the narcan underneath the tongue in the sublingual venous plexus... it is highly vascular and works fine.

Place a central line... It should take an ER physician no more than 3 minutes to establish a central line from start to finish during a code (minimal sterile technique--betadine and some sterile gloves). Once a patient goes into cardiac arrest, they need a definitive airway, and they are almost invariably going to need pressors, so even if an IV is already established, someone can start putting in a femoral line (easiest to access, no risk of PTX, CPR can still be administed while placing).

The other option if a peripheral IV can not be established is to place an I/O like margaritaboy pointed out.... Don't forget about venous cutdown as an option also.

Also... as a rule, you should never give any drugs SC to critically ill patients or during a code. In a code, I would avoid IM as well. People who are hypotensive clamp down their peripheral vasculature (including capillaries to their SC tissue) in order to maintain central perfusion. SC/IM drugs in general will have poor to no absorption (very unpredictable). This goes the same for Diabetic patients and DKA patients... start the insulin gtt, don't mess with SC administration until they are rescusitated and you're ready to turn the gtt off.
 
waterski232002 said:
If Narcan is needed and there is no IV, inject the narcan underneath the tongue in the sublingual venous plexus... it is highly vascular and works fine.

Place a central line... It should take an ER physician no more than 3 minutes to establish a central line from start to finish during a code (minimal sterile technique--betadine and some sterile gloves). Once a patient goes into cardiac arrest, they need a definitive airway, and they are almost invariably going to need pressors, so even if an IV is already established, someone can start putting in a femoral line (easiest to access, no risk of PTX, CPR can still be administed while placing).

The other option if a peripheral IV can not be established is to place an I/O like margaritaboy pointed out.... Don't forget about venous cutdown as an option also.

Also... as a rule, you should never give any drugs SC to critically ill patients or during a code. In a code, I would avoid IM as well. People who are hypotensive clamp down their peripheral vasculature (including capillaries to their SC tissue) in order to maintain central perfusion. SC/IM drugs in general will have poor to no absorption (very unpredictable). This goes the same for Diabetic patients and DKA patients... start the insulin gtt, don't mess with SC administration until they are rescusitated and you're ready to turn the gtt off.
Click to expand...

You're 3 months into your PGY-2 year, right?

You just always sound so dogmatic in your posts.
 
waterski232002 said:
If Narcan is needed and there is no IV, inject the narcan underneath the tongue in the sublingual venous plexus... it is highly vascular and works fine.

Place a central line... It should take an ER physician no more than 3 minutes to establish a central line from start to finish during a code (minimal sterile technique--betadine and some sterile gloves). Once a patient goes into cardiac arrest, they need a definitive airway, and they are almost invariably going to need pressors, so even if an IV is already established, someone can start putting in a femoral line (easiest to access, no risk of PTX, CPR can still be administed while placing).

The other option if a peripheral IV can not be established is to place an I/O like margaritaboy pointed out.... Don't forget about venous cutdown as an option also.

Also... as a rule, you should never give any drugs SC to critically ill patients or during a code. In a code, I would avoid IM as well. People who are hypotensive clamp down their peripheral vasculature (including capillaries to their SC tissue) in order to maintain central perfusion. SC/IM drugs in general will have poor to no absorption (very unpredictable). This goes the same for Diabetic patients and DKA patients... start the insulin gtt, don't mess with SC administration until they are rescusitated and you're ready to turn the gtt off.
Click to expand...
Nice...thanks for the explanations, everyone.
 
ttac said:
hehe... just because it _can_ be aerosolized doesn't mean it _has_ to be... you just draw out the epi with a syringe (should be 5mL of 1:1000)...
Click to expand...

I was just mentioning that you COULD draw out with a syringe, and what the concentration was in the croup nebulizer... not that you should give the whole quantity of 5mls in a code. Kind of a flippant answer to EC3 who was implying that I would give racemic epi via nebulizer during a code.

As far as my initial question, I emailed hospira and they said that our epi we use in codes was L-epi. The initial questions I wanted to know was:

Q: Is "code epi" racemic?
A: No, it's L-epi

Q: Can you use racemic epi in codes?
A: Well, for croup racemic epi is equivalent to L-epi, so apparently the D-isomer either has no effect, or has no different effect than L-epi, or at least does not counteract L-epi. So perhaps you can use racemic epi during a code instead of L-epi. I haven't seen any reason why not.

thanks for all the replies.
ttac

ttac
 
waterski232002 said:
Endotracheal Epi - both are also 1 mg doses and given with 1:10,000 solution.
Click to expand...

Is this true? I havnt gone back to look but I thought it was recommended that ET epi is performed using 1:1000 solution as to reduce the amount of fluid introduced to the lungs (which is one of the problems associated with ET meds).

As far as how much "extra" med to give for ET administration, we were taught in medic school to double or triple the dose, although the real amount necessary has not been researched and understood completely. It seems there is a delicate balance to be maintained between keeping fluid out of the lungs and providing therapeutic levels of the drug. ...Not to mention the other pharmacokinetic issues brought up by the other posters.. I thought it was these contributing factors that led the AHA to discourage ET administration. Still, it remains an option for paramedics unable to get a peripheral IV line. ...Although this too should become less of an issue with the increasing usage of adult IOs.
 
EC3 said:
i'll go ahead and field this one for the entire EM subforum...

who the **** gives a ****?!

/that'll do boys
Click to expand...

...and I'll go ahead and field this one for the entire EM subforum...

speak for yourself :laugh: :laugh: :laugh:

ttac
 
ttac said:
...and I'll go ahead and field this one for the entire EM subforum...

speak for yourself :laugh: :laugh: :laugh:

ttac
Click to expand...

And while everyone is obsessing over route (iv, et etc), isomers, dose and concentration in a code, let's remember that there is no evidence that epi (or any other drug) affects outcome favorably in cardiac arrest.

May have been EC3's point.:cool:
 
BKN said:
And while everyone is obsessing over route (iv, et etc), isomers, dose and concentration in a code, let's remember that there is no evidence that epi (or any other drug) affects outcome favorably in cardiac arrest.

May have been EC3's point.:cool:
Click to expand...

I've often though we (society) would be better off if we gave up on ACLS and devoted all those resources to preventive care. Instead of every nurse and doc spending a morning every 2 years in ACLS class we work in a clinic or whatever. I'm not really advocating this but it's an interesting idea. Imagine if we redirected all the resources that go into aeromed.
 
docB said:
I've often though we (society) would be better off if we gave up on ACLS and devoted all those resources to preventive care. Instead of every nurse and doc spending a morning every 2 years in ACLS class we work in a clinic or whatever. I'm not really advocating this but it's an interesting idea. Imagine if we redirected all the resources that go into aeromed.
Click to expand...

Coming up on 30 years as an ACLS instructor and I can't remember all the meds we've discarded: bicarb, bretyllium, lidocaine, . . . And the ones that are left are merely the least unproven.

I'd say do away with ACLS training except it's also good for organizing thinking and teamwork for the impending arrest as well. I think we can save a lot of lives with arrest prevention.

As for aeromed, it should be possible to define the unusual (in America) conditions where it actually is beneficial rather than detrimental. I suspect it would be only where there is urban traffic gridlock and in mountainous terrain.
 
Acls teaches that if one can not achieve iv access in a timely manner than io is the best way to go- this can be achieved in 15 seconds. Any med that can be given iv can be given io in the same concentration unlike via the et. Et is not reccomended any more because it is unknow med onset time and meds can accumalate in the body system and as medical providers we may not get the response we need immediately. Et can still be used if no iv access is available and due to trauma io also is not possible. I hope this clears up the many questions on what to do if we need to give meds and have no iv.
 
I gave ET epi last month on a witnessed v fib arrest. The patient lived to leave the hospital.
 
Dr.McNinja said:
I gave ET epi last month on a witnessed v fib arrest. The patient lived to leave the hospital.
Click to expand...
I'd wager it was the quick response and the electricity that saved them, not the ET epi. But congrats on the save!!! :thumbup:

On a related note, is there anything wrong with giving 1:1000 epi in a code (intravenously) if you don't have any preloaded 1:10,000 syringes, or should you grab some saline and dilute it first?
 
ttac said:
We're having this debate about epinephrine used in codes. I've seen an article referring to it as the L-isomer. I know that the body synthesizes L-epi and uses it exclusively instead of a racemic mixture. However, nobody ever refers to it as "racemic epi", which to me means that it must be either L-epi or D-epi, (likely L-epi). Does anybody know which one it is? Also if it IS L-epi, has there been any study comparing racemic epi and L-epi in codes? In croup they have been shown to be equivalent.
Click to expand...

Okay I know this is an extremely old thread and the point is probably moot by now, but I'm in my second semester of organic chemistry and I can't resist jumping at the chance to show off.

L-epinephrine is levorotary epinephrine, the stereoisomer of dextrorotary epinephrine (D-epinephrine). Only the levorotary isomer is biologically active, which is why L-epi is the only kind synthesized in the body. Racemic epi is by definition a 50/50 mixture of both the levorotary and dextrorotary isomers, a solution that I can only guess is used so as to dilute the potency of the drug. I work as a paramedic and when we give "racemic" epi we actually just mix our L-epi with saline, which (I guess) has a similar blunting effect.

Chiral compounds like epinephrine are found pretty frequently in medicine, often in the same scenario where one isomer will be biologically active while the other is not. Another interesting (to me, haha) example is glucose. Only Dextrorotary glucose is used in glycolysis, which is why we give Dextrose (DEXTRo-rotary glucOSE) to hypoglycemic patients. By convention, glucose synthesized outside the body is called "dextrose" while that synthesized in the body is called "glucose." The more you know....
 
Last edited:
fiznat said:
Chiral compounds like epinephrine are found pretty frequently in medicine, often in the same scenario where one isomer will be biologically active while the other is not.
Click to expand...

It's called a scam, when ofloxacin is marketed as new with levofloxacin, cetirizine with levocetirizine, albuterol with levalbuterol, omeprazole with esomeprazole, and modafanil with esmodafanil.

The more you know, indeed.
 
Except in this case(epi), the racemic mixture costs more than the isomer. I wonder why that is?
 
Dr.McNinja said:
Except in this case(epi), the racemic mixture costs more than the isomer. I wonder why that is?
Click to expand...

If I had to guess (as a former chemist), there are probably 2 different methods of manufacturing epi. The racemic epi may simply be produced through a largely chemical process with racemic starting compounds. The chirally pure compound may be produced through a mixed bio/chem process or a purely biologic process, which would pretty much force it to be chirally pure end result. Whichever one is cheaper simply depends on the price of the starter compounds and the price/efficiency of the technology used to do the reactions for the end result. So each will have a different price that varies with the economy and the technology independently.

Just a guess:)
 
Last edited:
You must log in or register to reply here.
Next unread thread

Similar threads

valianteffort
TPA at the end of a code
Replies
49
Views
2K
TooMuchResearch
T
C
Rapid response/code team doc? Does this exist anywhere?
Replies
18
Views
2K
alpinism
alpinism
valianteffort
What is your code recovery rate?
Replies
30
Views
2K
Janders
J
thegenius
Optum Billing and Coding
Replies
27
Views
2K
TysonCook
TysonCook
EctopicFetus
USACS Takes the L
2
Replies
56
Views
6K
Vandalia
V
Top