Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
A plea for caution in the use of adrenaline.
- Rakesh Khanna, W John Hawkins (19 May 1999)
-
Snake bite adrenaline premed protocol; should potential drug interactions be considered?
- Alan Watson (28 July 1999)
|
|
|||
|
Rakesh Khanna, SpR Accident & Emergency, Consultant in Intensive Care Staffordshire General Hospital, W John Hawkins
Send response to journal:
|
EDITOR: Premawardhene et al have demonstrated that low dose adrenaline can be safely administered by the sub-cutaneous route prophylactically prior to the administration of antivenom serum(1). They did not see an acute rise in blood pressure or other adverse sequelae. Fatal intracranial bleeding has however been documented following sub-cutaneous administration of adrenaline (2). Intravenous administration of adrenaline certainly does cause marked hypertension (3,4) which, as the sub cutaneous route can be catastrophic (5). We are also aware of a local case where the use of 2ml 1:10 000 Adrenaline given intravenously in a patient with moderate hypotension resulted in fatal cardiac arrhythmias. Adrenaline is currently being extensively used in the treatment of established anaphylaxis and cardiopulmonary arrest. Its use in a prophylactic role has now been described(1). We are deeply concerned that the medical profession is beginning to lose sight of the fact that adrenaline is a highly potent drug and must be used judiciously. Distinction should be made between the different routes of administration, although serious sequelae can ensue from its subcutaneous route these are far more likely if the intravenous route is chosen. Certainly, at present its use as a prophylactic agent should only be considered after detailed local protocols have been drawn up. References: 1.Premawardhena AP, de Silva CE, Fonseka MMD, Gunatilake, SB, de Silva HJ. Low dose subcutaneous adrenaline to prevent acute adverse reactions to antivenom serum in people bitten by snakes:randomised placebo controlled trial. BMJ 1999;318:730-3(17 April) 2.Horowitz BZ, Jadallah S, Derlet RW. Fatal intracranial bleeding associated with prehospital use of epinephrine. Ann Emerg Med 1996;28:725- 7. 3.[Accidental administration of racemic adrenaline. Three life-threatening cases after intravenous injection in children]. Tidsskr Nor Laegeforen 1998;118:1080-1 4. Hoffman BB, Lefkowitz RJ. Catecholamines, Sympathomimetic Drugs and Adrenergic Receptor Antagonists. In: Hardman JG, Limbird LE, eds. Goodman and Gilman’s, The Pharmacological Basis of Therapeutics. 9th Ed: New York. McGraw Hill 1996: 199-248. 5. Delodovici ML, Cavaletti G, Crespi V, Sanguineti I. Intracerebral hemorrhage following intravenous administration of epinephrine. Riv Neurol 1989;59:64-5. |
|||
|
|
|||
|
Alan Watson, General Practitioner Mooroopna Medical Centre 87 McLennan St Mooroopna Vic 3629 Australia
Send response to journal:
|
EDITOR: Premawardhena et al have listed medical contraindications to adrenaline premed administration to prevent acute adverse reactions to polyspecific antivenom serum in snake bite victims (1). I suggest that potential drug interactions should also be considered. Patients taking nonselective beta adrenergic receptor blockers could be at risk of an increased hypertensive response to parenteral adrenaline. Most patients on beta blockers would be excluded because of the underlying condition such as hypertension or ischaemic heart disease. Patients on beta blockers for migraine prophylaxis could be included. Patients taking drugs with alpha adrenergic receptor blocking activity could theoretically, via the reverse adrenaline effect, have a hypotensive response to parenteral adrenaline (2,3).Patients taking prazosin for hypertension would be excluded. Patients taking prazosin for bladder neck obstruction would not be excluded. There are very few published reports of clinical misadventure as a result of the reverse adrenaline effect (3). I suspect however that the many unexplained deaths in children (4,5) and adults on tricyclic antidepressants and/or phenothiazines are related to the fact that both of these groups of drugs have major alpha adrenergic receptor blocking activity. It is conceivable from accepted pharmacological principles that patients taking alpha adrenergic blockers who have a hypotensive collapse (from whatever cause- anaphylaxis, septicaemia, snake bite, vasovagal) would further drop their blood pressure as a result of a physiological endogenous adrenaline surge. Physician administered parenteral adrenaline in such patients could also exacerbate the hypotension possibly with fatal consequences (4,5). In summary snake bite victims taking adrenergic blockers may merit exclusion from adrenaline premed because of possible adverse drug interactions. References: 1. Premawardhena AP, de Silva CE, Fonseka MMD, Gunatilake SB, de Silva HJ. Low dose subcutaneous adrenaline to prevent acute adverse reactions to antivenom serum in people bitten by snakes: randomised, placebo controlled trial. BMJ 1999;318:1041-1043 (17 April). 2. Watson A. Don't get stung with the adrenergic blockers (beta or alpha). Australian Family Physician Vol. 24, No.10, October 1995 1879 3. Watson A. Alpha adrenergic blockers and adrenaline- a mysterious collapse. Australian Family Physician Vol. 27 No. 8, August 1998 714-715. 4. Popper CW, Zimnitzky B. Sudden death putatively related to desipramine treatment in youth: a fifth case and a review of speculative mechanisms. Journal Of Child And Adolescent Psychopharmacology Vol. 5, No. 4,1995 283-300. 5. Varley CK, McLennan J. Case study: two additional sudden deaths with tricyclic antidepressants. J.Am.Acad.Child Adolesc. Psychiatry 36:3, March 1997 390-394. |
|||