Racemic Epinephrine Vs. L Epinephrine 1:1000


Does anyone have any supporting documentation for the use of Racemic epinephrine over L epinephrine in croup patients? One fact that no one seems to acknowledge in studies that I've read is that you need 5cc's of L epinephrine 1:1000 to be equivalent to 0.5cc Racemic epinephrine. To me, this seems to be a major downfall when talking about giving a nebulizer treatment to a croupy baby and attempting NOT to create any more irritation to that child. (Anyone who has ever had to give a nebulizer to a croupy baby can agree that they usually don't like it and try to fight it.) The goal is always to give the medication in the most effective way and in the least stressful manner to the croupy child. A 5cc nebulizer treatment is a VERY long time for that child, especially when you can give racemic epinephrine in half the time. Unfortunately, all I can find is that racemic epinephrine and L epinephrine 1:1000 are just as effective as each other. When you consider the time difference involved with delivery and the type of patients it is often given to (croupy, stridorous children in distress - the kind you want to minimize agitation with), it seems the best option would be the racemic epinephrine. Does anyone have any resources that help support this? thanks!

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I realise this is a long time since you have posted this comment.

I am doing a study on the treatment of croup and have found that racemic epi has similar effects to L-epi at 30 minutes, but L-epi has been proven to have longer lasting effects lasting up to 120, whereas racemic lasts around 90 minutes.

Also when giving drugs via a nebuliser the minimum amount of fluid that provides best outcomes is 4 - 5mL which happens to be 5 ampuoles of 1:1000 adrenaline/epinephrine.

Also the literature states that when using racemic epinephrine it must be added to 0.9% NaCl in order to increase the volume being put into the nebuliser. So while the theory of getting the nebulisation over and done with quickly

I'm sure you have already found these answers but thought I would reply anyway.

This article is a review of relevant literature and has some interesting information.

Bjornson, C., Russell, K. F., Vandermeer, B., Durec, T., Klassen, T. P., & Johnson, D. W. (2011). Nebulized epinephrine for croup in children. Cochrane Database of Systematic Reviews, 2011(2). doi: 10.1002/14651858.CD006619.pub2

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It is important to not compare volume vs volume. One must compare dose vs dose. Typically one gives 3-5 cc of 1:1,000 epinephrine (0.3–0.5 mg) or 5 cc of recemic epinephrine 2.25% which is 11.25 mg. The way you write it the epinephrine seems to be the larger dose, but it is actually much smaller.

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You might want to double-check that quantity of Racemic Epi. The solution comes in a 0.5 cc (mL) ampule and not "5 cc" as you have written in your post.

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