Epinephrine Auto-Injectors Versus Manually Drawn Up Epinephrine: Is There a Better Option?*

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Anaphylaxis is an acute, life-threatening event that can lead to bronchoconstriction, airway edema, and shock. Prompt recognition and treatment with medication such as intramuscular administration of epinephrine can reverse symptoms and be lifesaving (1). Epinephrine is available for systemic use in many forms, including prefilled syringes, vials, and auto-injectors. Vials are available in multiple strengths (1 and 0.1 mg/mL), and the auto-injectors are available in different dosages (0.15 and 0.3 mg per auto-injector). The practitioner and the person administering must act quickly, efficiently, accurately, and often under stress, in order to prepare and deliver the epinephrine in a timely manner to benefit the patient suffering from anaphylaxis. Given the number of available preparations, errors may be more likely if healthcare providers are unfamiliar with the method of administration at the time of an event.
Chime et al (2), in this issue of Pediatric Critical Care Medicine, have provided a scoping literature review through 2014 of epinephrine injectable (EI) compared with epinephrine auto-injectors (EAI) to identify and compare medical errors associated with the use of either product in the treatment of anaphylaxis. Despite the broad inclusion and exclusion criteria, a total of 27 articles were identified. This reflects some important gaps in the literature, as the majority of the articles in their review were limited to observational or descriptive studies. Several common errors were highlighted when using EAIs, including failure to remove caps or identify the correct end for administration, inadequate needle length, improper technique (pressure or time applied, or self-injection into the thumb) sometimes leading to incorrect dosage. For EI, reports described errors associated with incorrect concentration selection, dosing, and incorrect route of administration (IV) that can result in significant cardiovascular side effects.
There are currently four available EAIs in the United States ranging in price from $187 to $2700 per device, based on average wholesale pricing (3). Given the necessity and lifesaving potential these products carry, the cost has gathered recent national attention in the mainstream news. The estimated cost to prepare a single dose of epinephrine including necessary supplies is $17.50 (2). It is quite clear the increased cost of the EAI is not based on drug price, but for the relative ease in which a nonhealthcare professional may be able to administer, or self-administer, a lifesaving medication in an emergency, with minimal to no training.
Despite thoughtful design, a total of 6,806 cases of unintentional EAI exposures, with the most common site being thumb or digit, were reported in a 2-year query of the American Association of Poison Control Center’s National Poison Data System (2013–2014) (4). In a survey conducted by Campbell et al (5), it is noted that ~ 2% of respondents (3/172) described a finger stick injury while using an EAI. Overall however, 82% of all healthcare providers in a single center ED preferred using EAIs over manual EI. EAIs were rated more favorably with regard to ease of use, convenience, dosing, and speed of administration. Manual EI was rated more favorably with regard to risk of provider self-injury and patient cost. The ease of use claim for EAIs would seem not to come from the product design, but rather the decreased cognitive burden associated with dosing and drug preparation, but not administration. Furthermore, recent discontinuation in May 2016 of labeling epinephrine vials with ratio expression and replacing with mass concentrations should reduce confusion during drug preparation.
Education on administration of EAIs may not be helpful to reduce the risks of self-injury. Robinson et al (6) described EAIs technique retention after education.

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