Which Adrenaline should be stocked in Dental and GP Practices?

Recently when one of my Practices had their Denplan inspection the Adrenaline they stock was discussed.  There appeared to be some confusion so I thought it would be useful to answer the question here.  Let’s start with looking at the recommended doses.

Resuscitation Council guidelines

The Resuscitation Council guidelines for the management of anaphylaxis recommend the following doses:-

Adults – 500mcg

Children of 12yrs and over – 500mcgs

Children 6-12 years – 300mcgs

Children 0-6 years – 150mcgs

 

So what should be stocked?

 

BNF recommendations

The Quality Standards for Dental Practices from the Resuscitation Council refer to the BNF for which emergency drugs should be stocked in Dental Practices.  In the list in the BNF it says you need to stock Adrenaline in a concentration of 1:1000 ie 1mg/1ml and suggest this should be ampoules.

In the text where it describes the management of anaphylaxis it talks about first maintaining the casualty’s airway and then treating the emergency:-

…administration of adrenaline (epinephrine) injection (section 3.4.3). This is given intramuscularly in a dose of 500 micrograms (0.5 mL adrenaline injection 1 in 1000); a dose of 300 micrograms (0.3 mL adrenaline injection 1 in 1000) may be appropriate for immediate self-administration.

 

Denplan recommendations

Denplan discuss the Adrenaline to be stocked on page 81 of the Quality Manual on the Denplan website, which you can access if you have a Denplan logon.  They say the following:-

  1. Adrenalin –1:1000 (this is: 1mg/ml dilution) used to treat severe allergic reactions. Route of administration should be intra muscular only (best in outer thigh).
  • Adults and children over 12 years old: 500mcg. That is 0.5ml
  • Patient<6yrs: 150mcg. That is 0.15ml
  • 6-12 years old: 300mcg. That is 0.3ml
  • If age not known: if small child or prepubescent – 300mcg

The need for syringes being able to measure small amounts is evident. Repeat after 5 minutes if required.

 

Back to the Resuscitation Council

The Resus Council also have an FAQs section on Anaphylaxis which you can read here.  Their previous objection to using autoinjectors in healthcare environments is that they are not available in the correct doses.  However, the last question on the FAQs addresses the availability of the Emerade autoinjector that is available in all 3 doses in a concentration of 1:1000; their advice is that this is a local decision, as quoted below:-

22. The Resuscitation Council (UK) guidance on anaphylaxis is aimed at healthcare professionals and does not reommned th use of auto-injecotrs by this group for several reasons such as shelf life, needle length, cost, and dose. There is a new product (Emerade) which appears to address some of these issues. What is the Council’s position on the use of Emerad by any healthcare professional?

The decision whether to use Emerade adrenaline auto-injector, another brand of auto-injector, or an ampoule, needle and syringe is a local decision. The decision should factor in the ease of implementation and the likelihood of anaphylaxis.

 

So what do you do?

Some of this information may at first glance seem contradictory.  However, the key underlying aim is to give the correct dose via the correct route.  My opinion is that where you have staff who are unable to, through a lack of confidence and competence, give intramuscular injections using a needle and syringe, then there is an argument for stocking autoinjectors.  This may be in either Dental or Medical practices.

The Emerade autoinjector mentioned above is available in a 500mcg, 300mcg and 150mcg dose.  It also has a longer shelf life, longer needle and shorter administration time.

Due to the guidance on dose from the Resuscitation Council I think it’s appropriate to stock the 500mcg and 300mcg doses plus ampoules.  If stocking ampoules you also need the appropriate syringes and needles to be able to give a 150mcg dose.  Therefore, a syringe that will measure 0.15ml is required.

Due to the advantages of the Emerade autoinjector I think this solution is cost effective and in an emergency enables the correct dose to be given.  If you only wish to stock one autoinjector then I would recommend the 500mcg and ensure you have syringes that can accurately measure 0.3mls and 0.15mls, and clinicians who are competent and confident in measuring and administering intramuscular injections.  Any decision needs to be considered locally and a local decision made.

I would like to add that I do not receive any benefits from the manufacturers or suppliers of Emerade.