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Ephedrine

Editor: Arpan Kohli Updated: 5/8/2023 12:00:36 AM

Indications

The FDA-approved primary indication for ephedrine is the treatment of clinically significant hypotension perioperatively. Induction of general and ongoing anesthesia during operative cases results in vasodilatation and hypotension, requiring treatment with vasopressors.[1]

It is also frequently the agent of choice for hypotension induced by spinal or epidural anesthesia. In obstetrics, sympathectomy during spinal anesthetics results in hypotension in 80% of patients.[2] Although phenylephrine selection is due to fewer effects on umbilical arterial acidity, ephedrine is a frequent choice due to less alpha-adrenergic action on the uterine vasculature, which preserves uterine blood flow.[3]

It is sometimes given intramuscularly to achieve a longer-lasting effect.[4] According to the American Society of Anesthesiologists Committee Task Force on obstetric anesthesia, ephedrine or phenylephrine can be utilized to treat hypotension during neuraxial anesthesia. However, in the absence of maternal bradycardia, phenylephrine is preferred.[5]

Since ephedrine results in both alpha and beta-adrenoreceptor stimulation, it is most beneficial in the setting of hypotension along with bradycardia or a low-normal heart rate, and caution is necessary for patients with hypotension and coexisting tachycardia. Most vasopressors used during anesthesia should be viewed as a temporizing measure while determining and addressing the source of hypotension.

Another notable indication of ephedrine is for allergy relief. Due to the constriction of smooth muscle via alpha receptor binding and bronchi dilation due to beta-2 receptor agonism, most sympathomimetics, including ephedrine, work effectively to decrease allergic symptoms.[6]

Oral formulations of ephedrine have been used historically to treat asthma via pulmonary vasoconstriction and reduction in airway edema along with beta-induced bronchodilation, but it is rarely used for this purpose in modern medicine due to unwanted cardiac effects and availability of more selective beta-agonists such as albuterol. Ephedrine is also available in a fixed-dose combination with guaifenesin to temporarily relieve mild asthma symptoms with an expectorant.[7]

Other off-label indications include bronchoconstriction, myasthenia gravis, and weight loss(in the past). In the early 2000s, the drug became very popular among over-the-counter supplements because it was found to work synergistically with caffeine to promote weight loss by stimulating metabolism.[8] However, ephedrine lost favor as a supplement after research established links to ventricular arrhythmias, nausea, and psychiatric issues with use.[9]

Patients with myasthenia gravis may also benefit from treatment with ephedrine; however, evidence for its specific mechanism of action and benefit in this disease has not come from randomized controlled trials, and only observational and non-randomized trials are currently available.[10] Lastly, case reports demonstrate using ephedrine to alleviate bronchoconstriction during induction for patients on beta-blocker maintenance therapy.[11]

Mechanism of Action

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Mechanism of Action

Ephedrine, a stereoisomer to better-known pseudoephedrine, is a sympathomimetic amine with unique effects due to its indirect mechanism than other sympathomimetic agents like pseudoephedrine and phenylephrine.[12] Ephedrine acts as both a direct and indirect sympathomimetic. It binds directly to both alpha and beta receptors; however, its primary mode of action is indirectly achieved by inhibiting neuronal norepinephrine reuptake and displacing more norepinephrine from storage vesicles.[13] This action allows norepinephrine to remain in the synapse longer to bind postsynaptic alpha and beta receptors.[14]

Ephedrine’s indirect mechanism results in a sustained or even increased heart rate due to norepinephrine’s ability to bind alpha and beta receptors, whereas more direct sympathomimetics like phenylephrine results in reflex bradycardia. While the indirect effect is most profound on arterial blood pressure, the direct vasoconstricting action functions more on the venous system. It is, therefore, effective in elevating central venous pressure when the patient is challenged with fluids.[13]

Stimulation of alpha-1-adrenergic smooth muscle receptors within vasculature results in a rise in systemic vascular resistance and, consequently, systolic and diastolic blood pressure. Direct stimulation of beta-1 receptors by ephedrine and norepinephrine increases cardiac chronotropy and inotropy. Finally, beta-2-adrenergic receptor stimulation in the lungs results in bronchodilation with ephedrine administration, though it is not as pronounced as its cardiovascular effects.[15]

Pharmacokinetics

Absorption: Oral ephedrine attains peak plasma concentration at 1.8 hours and has a bioavailability of 88%.

Distribution: Oral ephedrine has a volume of distribution of 215.6 Liters. Ephedrine can cross the placental barrier.[16]

Metabolism: Ephedrine is metabolized into norephedrine. The parent drug and its metabolite are both excreted in the urine.

Elimination: Limited clinical data after intravenous administration of ephedrine endorses similar observations of urinary excretion. The plasma elimination half-life of ephedrine after oral administration is approximately 6 hours. The urinary excretion of ephedrine is increased in acidic urine.[17] nephrolithiasis induced by an excessive dose of ephedrine has been treated with urinary alkalinization.[18][17]

Administration

Dosage Formulations

  • Ephedrine sulfate oral tablet: 25 mg
  • Ephedrine hydrochloride intravenous solution: 23.5 mg/5 mL
  • Ephedrine sulfate intravenous solution: 5 mg/mL; 50 mg/mL
  • Fixed dose combination of oral ephedrine hydrochloride 12.5 mg/guaifenesin 200 mg

For the treatment of asthma, 25 mg tablets are used every four hours as needed, and the maximum dose should not exceed 150 mg in 24 hours. For adults, bolus dose recommendations are 5 to 10 mg, and intramuscular doses for a prolonged desired effect are 25 to 50 mg.[13] Ephedrine requires dilution before intravenous use.

When treating hypotension, cardiovascular effects via the indirect mechanism depend on adequate native norepinephrine stores. Tachyphylaxis will develop with prolonged and repeated use as this depletes endogenous norepinephrine stores. For this reason, it is administered in intravenous boluses when used intravenously and rarely as a continuous infusion.

Specific Patient Populations

Patients with Hepatic Impairment: No dosage adjustments have been provided in the package insert. Use with caution.

Patients with Renal Impairment: According to the manufacturer's prescribing information, ephedrine and its metabolite are excreted in the urine. In patients with kidney disease, excretion of ephedrine is affected with a corresponding increase in elimination half-life, which will lead to the slow elimination of ephedrine and consequently prolonged pharmacological effect and potential adverse reactions. Therefore, carefully monitor patients with renal impairment after the initial bolus dose for adverse events.

Pregnancy Considerations: Though ephedrine is frequently used in obstetric patients just before and during delivery, there is insufficient data to support using the drug in earlier stages of pregnancy, and no animal reproductive studies have been performed, making it a category C drug in pregnancyEphedrine should be given to a pregnant woman only if indicated.[19]

Breastfeeding Considerations: A single published case report indicates that ephedrine is present in human breast milk. Nonetheless, no information is available on the effects of ephedrine on the breastfed infant or the effects on milk production. Clinicians should consider the risk-benefit analysis for the mother's clinical requirement for ephedrine and adverse reactions in the breastfed child from ephedrine. Administration to the nursing women is not recommended as there is a higher-than-usual risk for infants, according to the package insert. 

Pediatric Patients: The FDA has not formally established safety and effectiveness in pediatric populations.[2] However, it is used off-label to treat hypotension induced by anesthesia.[20][21]

Elderly Patients: The dose of ephedrine should be initiated at the low end of the dosing range, considering the higher frequency of decreased hepatic, renal, or cardiac function.

Adverse Effects

Ephedrine may produce palpitations, headache, dizziness, nausea, vomiting, restlessness, and anxiety in the conscious patient. Ephedrine is also arrhythmogenic, and clinicians should be cautious when administering patients predisposed to arrhythmias or taking other arrhythmogenic medications, particularly digitalis. When used long-term, the catecholamine excess can result in contraction band necrosis of the myocardium, which predisposes the heart to ventricular arrhythmias.[22]

Another common effect of ephedrine is an alteration in the time until the onset and duration of action of other drugs. This effect is most notable during induction when giving ephedrine to a hypotensive patient before rocuronium.[23][24]

Additionally, ephedrine may be hepatotoxic, but there seems to be unclear evidence. This idea stems from case reports where ephedra species containing several compounds resulted in liver damage instead of a direct correlation.[25]

A less common effect experienced mostly by illicit users of ephedrine and its derivatives is the development of radiolucent urological ephedrine-containing stones and paranoid schizophrenia.[26]

Drug-Drug Interactions

  • Augmentation of the blood pressure: Clonidine, oxytocin, and propofol can increase blood pressure when administered with ephedrine.[27][28]
  • Interactions that antagonize the pressor effect: α-adrenergic antagonists, β-adrenergic antagonists, and reserpine can antagonize the vasopressor effect of ephedrine.
  • Guanethidine: Ephedrine may inhibit the neuron blockage induced by guanethidine, resulting in loss of antihypertensive efficacy. 
  • Rocuronium: Ephedrine may decrease the onset time of neuromuscular blockade when used with rocuronium for intubation if administered simultaneously. No interventions are needed.[24]
  • Theophylline: Concomitant use of ephedrine and theophylline may increase nervousness and insomnia.
  • Cardiac glycosides: Administering ephedrine with a cardiac glycoside, such as digitalis, may increase the likelihood of arrhythmias. Monitor patients on digoxin who are administered ephedrine.[29]

Contraindications

Ephedrine is contraindicated in a patient with acute hypertension or tachycardia. Ephedrine increases both chronotropy and inotropy and therefore increases myocardial oxygen demand, and its use requires caution in patients with ischemic heart disease or heart failure. It should also be avoided when tachycardia is undesirable, such as aortic stenosis. Alpha-adrenergic stimulation caused by ephedrine results in the contraction of the smooth muscle at the base of the bladder, resulting in resistance to urine outflow, and caution is necessary for patients with urinary retention and prostatic hyperplasia.[15]

Ephedrine should be avoided or used with caution within 14 days of MAOI therapy due to excessive norepinephrine availability at the synapse, which could cause a hypertensive crisis through the indirect sympathomimetic effect of ephedrine.[30]

Norepinephrine and phenylephrine are other appropriate choices to maintain blood pressure post-spinal anesthesia. Norepinephrine was shown to have fewer episodes of hypotension than ephedrine, and phenylephrine showed less extensive effects on umbilical artery acidity.[31][32]

Monitoring

Although there are no specific drug monitoring requirements, variations in gene codons for receptor type can yield various sensitivities to ephedrine. Specifically, variations at codons 16 and 27 for the beta-2 adrenoreceptor have significant differences in ephedrine requirement to combat hypotension post-spinal anesthesia. Due to the variation in responses and the fact that vasoactive medications can immediately affect blood pressure, heart rate, and pulse oximetry require close monitoring.[33]

Toxicity

According to the manufacturer's prescribing information, an overdose of ephedrine can cause a rapid rise in blood pressure. In the case of an overdose, careful blood pressure monitoring is recommended. If blood pressure rises to an unacceptable level, parenteral antihypertensive agents can be administered at the clinician's discretion. 

Signs and Symptoms: The principal manifestation of ephedrine poisoning is hypertension and convulsions. A case report of cardiomyopathy and spinal artery vasospasm leading to quadriplegia has been noted.[34]

Treatment: If respirations are shallow or cyanosis is present, secure the airway and provide mechanical ventilation.

Antidote: For hypertension, 5 mg phentolamine mesylate diluted in saline may be administered slowly intravenously, or clinicians may give 100 mg orally. Convulsions may be controlled by benzodiazepines.

Enhancing Healthcare Team Outcomes

Though anesthetists and certified registered nurse anesthetists (CRNA) are some of the only providers to administer ephedrine routinely, they do not do so within a vacuum. All interprofessional healthcare team members, including physicians, mid-level practitioners, nurses, and pharmacists providing care for the patient, should know its effects and different routes of administration. When given intravenously, drug effects are often of short duration (minutes), and tachyphylaxis is common. However, if given intramuscularly, the vasopressor effects typically remain for 60 to 90 minutes.[13]

These effects are significant in the labor and delivery ward. Patients often receive intramuscular ephedrine injections following a spinal block to attenuate the sympathectomy and nausea that frequently accompany spinal blockade. The effects of an IM injection may last much longer than the procedure itself, and nurses and clinicians should not rely on hypotension as the primary indicator of postpartum hemorrhage, as IM ephedrine may mask this sign.

When planning to use ephedrine, the pharmacist should verify the dose and that there are no significant drug-drug interactions and report these findings to the clinical team. Nursing must be mindful of the adverse effects of the drug and be prepared to inform the clinician regarding their observations. Nurse anesthetists (CRNAs) are also commonly involved in administration, so they must collaborate on dosing and administration with the pharmacist. Monitoring the patient following administration is the responsibility of all team members, and they must all be empowered to speak up if there are any concerns so interventions can be initiated if necessary.

These examples show how all interprofessional team members, including MDs, DOs, NPs, PAs, nurses, specialists, and pharmacists, can optimize outcomes related to ephedrine therapy while mitigating its adverse effects. [Level 5]

References


[1]

Südfeld S, Brechnitz S, Wagner JY, Reese PC, Pinnschmidt HO, Reuter DA, Saugel B. Post-induction hypotension and early intraoperative hypotension associated with general anaesthesia. British journal of anaesthesia. 2017 Jul 1:119(1):57-64. doi: 10.1093/bja/aex127. Epub     [PubMed PMID: 28974066]


[2]

Clark RB, Thompson DS, Thompson CH. Prevention of spinal hypotension associated with Cesarean section. Anesthesiology. 1976 Dec:45(6):670-4     [PubMed PMID: 984486]


[3]

Guo R, Xue Q, Qian Y, Hu Y, Tan J. The Effects of Ephedrine and Phenylephrine on Placental Vascular Resistance During Cesarean Section Under Epidual Anesthesia. Cell biochemistry and biophysics. 2015 Dec:73(3):687-93. doi: 10.1007/s12013-015-0676-7. Epub     [PubMed PMID: 27259311]

Level 2 (mid-level) evidence

[4]

Mon W, Stewart A, Fernando R, Ashpole K, El-Wahab N, MacDonald S, Tamilselvan P, Columb M, Liu YM. Cardiac output changes with phenylephrine and ephedrine infusions during spinal anesthesia for cesarean section: A randomized, double-blind trial. Journal of clinical anesthesia. 2017 Feb:37():43-48. doi: 10.1016/j.jclinane.2016.11.001. Epub 2016 Dec 26     [PubMed PMID: 28235526]

Level 1 (high-level) evidence

[5]

. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2016 Feb:124(2):270-300. doi: 10.1097/ALN.0000000000000935. Epub     [PubMed PMID: 26580836]

Level 1 (high-level) evidence

[6]

Laccourreye O, Werner A, Giroud JP, Couloigner V, Bonfils P, Bondon-Guitton E. Benefits, limits and danger of ephedrine and pseudoephedrine as nasal decongestants. European annals of otorhinolaryngology, head and neck diseases. 2015 Feb:132(1):31-4. doi: 10.1016/j.anorl.2014.11.001. Epub 2014 Dec 19     [PubMed PMID: 25532441]


[7]

Anderson SD. Repurposing drugs as inhaled therapies in asthma. Advanced drug delivery reviews. 2018 Aug:133():19-33. doi: 10.1016/j.addr.2018.06.006. Epub 2018 Jun 12     [PubMed PMID: 29906501]


[8]

Astrup A, Toubro S, Christensen NJ, Quaade F. Pharmacology of thermogenic drugs. The American journal of clinical nutrition. 1992 Jan:55(1 Suppl):246S-248S. doi: 10.1093/ajcn/55.1.246s. Epub     [PubMed PMID: 1345887]


[9]

Rakovec P, Kozak M, Sebestjen M. Ventricular tachycardia induced by abuse of ephedrine in a young healthy woman. Wiener klinische Wochenschrift. 2006 Sep:118(17-18):558-61     [PubMed PMID: 17009070]

Level 3 (low-level) evidence

[10]

Vrinten C, van der Zwaag AM, Weinreich SS, Scholten RJ, Verschuuren JJ. Ephedrine for myasthenia gravis, neonatal myasthenia and the congenital myasthenic syndromes. The Cochrane database of systematic reviews. 2014 Dec 17:2014(12):CD010028. doi: 10.1002/14651858.CD010028.pub2. Epub 2014 Dec 17     [PubMed PMID: 25515947]

Level 1 (high-level) evidence

[11]

Oshika H, Koyama Y, Usuda Y, Andoh T. Intravenous ephedrine abolished suspected bronchoconstriction during general anesthesia in a patient undergoing beta-adrenergic blocker therapy for hypertension. Saudi journal of anaesthesia. 2019 Jan-Mar:13(1):63-65. doi: 10.4103/sja.SJA_367_18. Epub     [PubMed PMID: 30692891]


[12]

Radiloff D, Zhao Y, Boico A, Blueschke G, Palmer G, Fontanella A, Dewhirst M, Piantadosi CA, Noveck R, Irwin D, Hamilton K, Klitzman B, Schroeder T. Anti-hypotensive treatment and endothelin blockade synergistically antagonize exercise fatigue in rats under simulated high altitude. PloS one. 2014:9(6):e99309. doi: 10.1371/journal.pone.0099309. Epub 2014 Jun 24     [PubMed PMID: 24960187]

Level 3 (low-level) evidence

[13]

Becker DE. Basic and clinical pharmacology of autonomic drugs. Anesthesia progress. 2012 Winter:59(4):159-68; quiz 169. doi: 10.2344/0003-3006-59.4.159. Epub     [PubMed PMID: 23241039]


[14]

Kobayashi S, Endou M, Sakuraya F, Matsuda N, Zhang XH, Azuma M, Echigo N, Kemmotsu O, Hattori Y, Gando S. The sympathomimetic actions of l-ephedrine and d-pseudoephedrine: direct receptor activation or norepinephrine release? Anesthesia and analgesia. 2003 Nov:97(5):1239-1245. doi: 10.1213/01.ANE.0000092917.96558.3C. Epub     [PubMed PMID: 14570629]

Level 3 (low-level) evidence

[15]

Piascik MT, Perez DM. Alpha1-adrenergic receptors: new insights and directions. The Journal of pharmacology and experimental therapeutics. 2001 Aug:298(2):403-10     [PubMed PMID: 11454900]

Level 3 (low-level) evidence

[16]

Ngan Kee WD, Khaw KS, Tan PE, Ng FF, Karmakar MK. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology. 2009 Sep:111(3):506-12. doi: 10.1097/ALN.0b013e3181b160a3. Epub     [PubMed PMID: 19672175]

Level 1 (high-level) evidence

[17]

Feller DR, Malspeis L. Biotransformation of D(-)-ephedrine and L(+)-ephedrine in the rabbit, in vivo and in vitro. Drug metabolism and disposition: the biological fate of chemicals. 1977 Jan-Feb:5(1):37-46     [PubMed PMID: 13974]

Level 3 (low-level) evidence

[18]

Hoffman N, McGee SM, Hulbert JC. Resolution of ephedrine stones with dissolution therapy. Urology. 2003 May:61(5):1035     [PubMed PMID: 12736038]

Level 3 (low-level) evidence

[19]

Leek JC, Arif H. Pregnancy Medications. StatPearls. 2023 Jan:():     [PubMed PMID: 29939635]


[20]

de Graaff JC, Frykholm P. Ephedrine to treat intraoperative hypotension in infants: what is the target? British journal of anaesthesia. 2023 May:130(5):510-515. doi: 10.1016/j.bja.2023.02.007. Epub 2023 Mar 9     [PubMed PMID: 36906461]


[21]

Szostek AS, Saunier C, Elsensohn MH, Boucher P, Merquiol F, Gerst A, Portefaix A, Chassard D, De Queiroz Siqueira M. Effective dose of ephedrine for treatment of hypotension after induction of general anaesthesia in neonates and infants less than 6 months of age: a multicentre randomised, controlled, open label, dose escalation trial. British journal of anaesthesia. 2023 May:130(5):603-610. doi: 10.1016/j.bja.2022.12.006. Epub 2023 Jan 12     [PubMed PMID: 36639328]

Level 1 (high-level) evidence

[22]

Casella M, Dello Russo A, Izzo G, Pieroni M, Andreini D, Russo E, Colombo D, Bologna F, Bolognese L, Zeppilli P, Tondo C. Ventricular arrhythmias induced by long-term use of ephedrine in two competitive athletes. Heart and vessels. 2015 Mar:30(2):280-3. doi: 10.1007/s00380-013-0455-6. Epub 2014 Jan 4     [PubMed PMID: 24390726]

Level 3 (low-level) evidence

[23]

Santiveri X, Mansilla R, Pardina B, Navarro J, Alvarez JC, Castillo J. [Ephedrine shortens the onset of action of rocuronium but not atracurium]. Revista espanola de anestesiologia y reanimacion. 2003 Apr:50(4):176-81     [PubMed PMID: 12825305]

Level 1 (high-level) evidence

[24]

Leykin Y, Pellis T, Lucca M, Gullo A. Effects of ephedrine on intubating conditions following priming with rocuronium. Acta anaesthesiologica Scandinavica. 2005 Jul:49(6):792-7     [PubMed PMID: 15954961]

Level 1 (high-level) evidence

[25]

Willson C. Sympathomimetic amine compounds and hepatotoxicity: Not all are alike-Key distinctions noted in a short review. Toxicology reports. 2019:6():26-33. doi: 10.1016/j.toxrep.2018.11.013. Epub 2018 Dec 1     [PubMed PMID: 30581759]


[26]

Skeldon SC, Goldenberg SL. Urological complications of illicit drug use. Nature reviews. Urology. 2014 Mar:11(3):169-77. doi: 10.1038/nrurol.2014.22. Epub 2014 Feb 18     [PubMed PMID: 24535583]


[27]

Ishiyama T, Kashimoto S, Oguchi T, Matsukawa T, Kumazawa T. The effects of clonidine premedication on the blood pressure and tachycardiac responses to ephedrine in elderly and young patients during propofol anesthesia. Anesthesia and analgesia. 2003 Jan:96(1):136-41, table of contents     [PubMed PMID: 12505939]

Level 1 (high-level) evidence

[28]

Goyagi T, Tanaka M, Nishikawa T. Oral clonidine premedication enhances the pressor response to ephedrine during spinal anesthesia. Anesthesia and analgesia. 1998 Dec:87(6):1336-9     [PubMed PMID: 9842823]

Level 1 (high-level) evidence

[29]

Zhuang W, He T, Jia BB, Wang ZZ, Zhang L, Dong XZ, Xi SY. Interaction between Chinese medicine and digoxin: Clinical and research update. Frontiers in pharmacology. 2023:14():1040778. doi: 10.3389/fphar.2023.1040778. Epub 2023 Feb 7     [PubMed PMID: 36825153]


[30]

Dingemanse J, Guentert T, Gieschke R, Stabl M. Modification of the cardiovascular effects of ephedrine by the reversible monoamine oxidase A-inhibitor moclobemide. Journal of cardiovascular pharmacology. 1996 Dec:28(6):856-61     [PubMed PMID: 8961085]

Level 1 (high-level) evidence

[31]

Hassani V, Movaseghi G, Safaeeyan R, Masghati S, Ghorbani Yekta B, Farahmand Rad R. Comparison of Ephedrine vs. Norepinephrine in Treating Anesthesia-Induced Hypotension in Hypertensive Patients: Randomized Double-Blinded Study. Anesthesiology and pain medicine. 2018 Aug:8(4):e79626. doi: 10.5812/aapm.79626. Epub 2018 Aug 26     [PubMed PMID: 30271750]

Level 1 (high-level) evidence

[32]

Heesen M, Rijs K, Hilber N, Ngan Kee WD, Rossaint R, van der Marel C, Klimek M. Corrigendum to "Ephedrine versus phenylephrine as a vasopressor for spinal anaesthesia-induced hypotension in parturients undergoing high-risk caesarean section: meta-analysis, meta-regression and trial sequential analysis" [Int J Obstet Anesth 2019;37:16-28]. International journal of obstetric anesthesia. 2019 Aug:39():152. doi: 10.1016/j.ijoa.2019.05.003. Epub 2019 Jun 6     [PubMed PMID: 31178233]


[33]

Almustafa MM, Al-Oweidi AS, Al-Zaben KR, Qudaisat IY, Abu-Halaweh S, Alghanem SM, Massad IM, Samarah W, Al-Shaer RA, Ismail S, Khazawla F. Ephedrine requirements during spinal anesthesia for cesarean delivery in Jordanian parturients: association with b2 adrenoceptor gene variants. Annals of Saudi medicine. 2016 Jan-Feb:36(1):29-36. doi: 10.5144/0256-4947.2016.29. Epub     [PubMed PMID: 26922685]


[34]

Snipelisky DF, Kurklinsky AK, Chirila R. Transient Cardiomyopathy and Quadriplegia Induced by Ephedrine Decongestant. Texas Heart Institute journal. 2015 Dec:42(6):575-8. doi: 10.14503/THIJ-14-4487. Epub 2015 Dec 1     [PubMed PMID: 26664316]