Adrenaline quick review

• Hormone description: a catecholamine and belongs to the family of biogenic amines, synthesized in the neurones of the adrenal medulla and stored in the chromaffin granula.

• Biological functions: a natural antidote to the chemicals released during severe allergic reactions triggered by drug allergy, food allergy or insect allergy.

• Health benefits : used as sympathicomimeticum, broncholyticum and antiasthmaticum; prevents bleedings during surgery or in the case of inner organ bleeding.

• Side effects: contraindicated in patients with narrow-angle glaucoma, hypersensitivity to epinephrine, side effects include tremor, excitability, vomiting, hypertension , arrhythmias, hyperuricemia.

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Adrenaline (epinephrine)

Adrenaline is a catecholamine and belongs to the family of biogenic amines. Adrenaline is a natural stimulant made in the adrenal gland of the kidney. Its biological name is epinephrine, from the Greek nephros for kidney. Adrenaline is carried in the bloodstream and affects the autonomous nervous system, which controls functions such as the heart rate, dilation of the pupils, and secretion of sweat and saliva. L-adrenaline was the first hormone which could be crystallized. Adrenaline is synthesized in the neurones of the adrenal medulla and stored in the chromaffin granula. An activating signal, which can be induced through a low blood glucose level, triggers the release of adrenaline into the blood. Adrenaline is the body's activator, and is released in response to anxiety, exercise, or fear. Adrenaline can be produced synthetically for medical purposes. Adrenaline is secreted by the adrenal medulla in response to low blood glucose, exercise and stress and causes a breakdown of glycogen to glucose in the liver, encourages the release of fatty acids from adipose tissue, causes vasodilation of the small arteries within muscle and increases cardiac output. Adrenaline is air and light sensitive and forms dark products during decomposition.

The biological functions of adrenaline

Adrenaline is the primary catecholamine released from the adrenal medulla in response to stimulation, and is responsible for

increases in neural activity (alertness), cardiac output and blood pressure. Adrenaline is a natural antidote to the chemicals released during severe allergic reactions triggered by drug allergy, food allergy or insect allergy. Adrenaline has the opposite effect of insuline. It is a first messenger hormone and will be released when the glucose level in blood is low. Adrenaline belongs to the family of adrenal medulla hormones. The hormone has a big influence on the storage and mobilisation of glycogene and fatty acids and the corresponding metabolic pathways. Adrenaline is a direct-acting sympathomimetic agent exerting its effect on alpha and beta adrenoreceptors. Major effects are increased systolic blood pressure, reduced diastolic pressure, tachycardia, hyperglycaemia and hypokalaemia. It is a powerful cardiac stimulant. It has vasopressor properties, an antihistaminic action and is a bronchodilator. Its action is rapid in onset and of short duration. Adrenaline’s action is thought to be mainly through its alpha agonist activity, mediating powerful peripheral vasoconstricton, increasing diastolic aortic pressure and thereby improving coronary artery blood flow. Adrenaline triggers the adenylatcyclase cascade (or cAMP cascade). This activating cascade effects the mobilisation of glycogene (liver) and triacylglycerines (fat tissue) and a generel increase of the metabolic rate. The resulting rise in blood sugar enables the fermentation of glucose in the muscles. Adrenaline furthermore reinforces these effects, because it increases the secretion of glucagon (a hormone with the same effects as adrenaline) and decreases the release of insulin. Adrenaline works also as neurotransmitter and has an effect on the sympathetic nervous system (heart, lungs, blood vessels, bladder, gut and genitalia). This neurotransmitter will be realeased by nervous stimulation in response to physical or mental stress and binds to a special group of transmembrane proteins.

Usages and indications

Adrenaline is used as sympathicomimeticum, broncholyticum and antiasthmaticum. It also is used to staunch or prevent bleedings during surgery or in the case of inner organ bleeding. Adrenaline is administered in combination with local anaesthetics. In this combination, anaesthetics have a longer lasting effect and can be administered in smaller doses. Generally adrenaline is implicated in arousal. Within the body, adrenaline acts in such a way as to maintain an activated state, allowing a higher state of energy to be produced. Within the brain, it is also implicated in emotional states. Adrenaline is used to treat glaucoma. Glaucoma is caused by a blockage in the eye, which prevents fluid leaving the eye, causing pressure to build up within the eye. This can cause pain and discomfort. Adrenaline works by opening. Adrenaline is the recommended first line treatment for patients with anaphylaxis. Anaphylaxis is the clinical syndrome representing the most severe systemic allergic reactions. Adrenaline stimulates adrenoceptors to increase peripheral vascular resistance thus improving blood pressure and coronary perfusion, reversing peripheral vasodilation, and decreasing angioedema.

Contraindications, interactions, precautions, side effects

Adrenaline is contraindicated in patients with narrow-angle glaucoma, hypersensitivity to epinephrine, shock due to non-anaphylactoid causes, during general anesthesia with halogenated hydrocarbons or cyclopropane, during labor (may delay the second stage) and in cardiac dilatation or coronary insufficiency.

Adrenaline should not be used in the presence of cardiac dilation. Adrenaline should not be used in most patients with arrhythmias and cerebral arteriosclerosis, where vasopressor drugs may be contraindicated eg. in thyrotoxicosis, in obstetrics when maternal blood pressure is in excess of 130/80 mm/Hg. Adrenaline is also contraindicated in shock (other than anaphylactic shock), in patients with organic brain damage, during general anaesthesia with halogenated hydrocarbons or cyclopropane. Adrenaline should not be injected into fingers, toes, ears, nose or genitalia.

Adrenaline can induce a feeling of fear or anxiety, tremor, excitability, vomiting, hypertension (overdosage), arrhythmias (especially if patient has organic heart disease or has received another drug that sensitizes the heart to arrhythmias), hyperuricemia, and lactic acidosis (prolonged use or overdosage). Repeated injections can cause necrosis at the injection site. Use with caution in patients with ventricular fibrillation, prefibrillatory rhythm, tachycardia, myocardial infarction, phenothiazine induced circulatory collapse and prostatic hypertrophy. Administer slowly with caution to elderly patients and to patients with hypertension, diabetes mellitus, hyperthyroidism and psychoneurosis. Use with extreme caution in patients with long-standing bronchial asthma and emphysema who have developed degenerative heart disease. Anginal pain may be induced when coronary insufficiency is present. Use with caution in patients with narrow angle glaucoma.

Adrenaline should not be administered with other sympathomimetic agents because of the danger of additive effects and increased toxicity. Halothane and other anaesthetics such as cyclopropane and trichlorethylene increase the risk of adrenaline - induced ventricular arrhythmias and acute pulmonary oedema if hypoxia is present. Adrenaline is physically incompatible with alkalis, metals, oxidising agents, sodium warfarin, hyaluronidase and many other drugs; it forms polymers with sodium bicarbonate.

Common side effects are those of increased heart rate, an increase in blood pressure, thumping of the heart, shaking, nervousness or a transient headache. Psychomotor agitation, disorientation, impaired memory and psychosis may occur. The potentially severe adverse effects of adrenaline arise from its effect upon blood pressure and cardiac rhythm. Ventricular fibrillation may occur and severe hypertension may lead to cerebral haemorrhage and pulmonary oedema. Overdosage of adrenaline can result in severe metabolic acidosis because of elevated blood concentration of lactic acid. Symptoms seen with overdosage or inadvertent IV administration of SQ or IM dosages can include: sharp rises in systolic, diastolic, and venous blood pressures, cardiac arrhythmias, pulmonary edema and dyspnea, vomiting, headache, and chest pain. Cerebral hemorrhages may result because of the increased blood pressures. Renal failure, metabolic acidosis and cold skin may also result.