Basic of Vasopressors, Part 2: Epinephrine

About epinephrine 

  • Mechanism of action: epinephrine’s mechanism of action can be divided into low-dose (2-3 μg/min) and high-dose ( 3 μg/min) actions. At low doses, epinephrine favors β1 and β2 agonism. As β1 receptors are on the heart, epinephrine at low doses increases both chronotropy and inotropy. β2 receptors are on the vasculature, and they cause vasodilation. Thus, epinephrine at low doses decreases preload, afterload, and systemic vascular resistance. Agonism of β2 receptors with epinephrine also causes bronchodilation, and low doses of epinephrine can be useful for patients with obstructive pulmonary pathology. However, at high doses, the β2 effect falls off, and the α1 effect becomes more significant. Thus, at high doses, epinephrine increases preload, afterload, and systemic vascular resistance.  

  • Uses: go-to agent for anaphylaxis and cardiac arrest. Also great for cardiogenic shock because of its effects on chronotropy and inotropy  

  • Avoid: can worsen primary tachyarrhythmias because of its propensity to increase chronotropy and inotropy, and can worsen supply/demand mismatch in critical aortic stenosis due to the fact that the heart is now beating harder against a fixed afterload  

For comparison, here's our 'obligatory' pressor table:

 

References:

  • Farkas, Josh. The Internet Book of Critical Care. Vasopressors. Accessed on December 7th, 2021. Available at https://emcrit.org/ibcc/pressors/ 

  • Farkas, Josh. The Internet Book of Critical Care Podcast 78 – Vasoactive Agents. Published on February 20th, 2020. Accessed on December 7th, 2021. Available at https://emcrit.org/pulmcrit/pressors/ 

  • Kim SM, Aikat S, Bailey A. Well recognised but still overlooked: norepinephrine extravasation. BMJ Case Reports 2012;2012:bcr2012006836:. doi: 10.1136/bcr-2012-006836. 

  • Khanna, A et al. Angiotensin II for the treatment of vasodilatory shock. NEJM 2017;377:419-430. doi: 10.1056/NEJMoa1704154. 

  • Manaker, Scott. Use of vasopressors and inotropes. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. (Accessed December 7th, 2021)  

  • Parekh M, Andreae M. EM Resident. The Crashing Patient with Critical Aortic Stenosis. Published October 3rd, 2017. Accessed on December 9th, 2021. Available at https://www.emra.org/emresident/article/the-crashing-patient-with-critical-aortic-stenosis/. 

  • Rezaie, Salim. Rebel EM. Peripheral Pressors: 6 Pearls Not to F*#k Up the Arm. Published on June 4th, 2020. Accessed on December 7th, 2021. Available at https://rebelem.com/peripheral-pressors-6-pearls-to-not-fk-up-the-arm/ 

  • Shields SH, Holland RM. Pharmacology of vasopressors and inotropes. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th edition. New York, NY: McGraw-Hill Education; 2020: 133-137.