From the Guidelines
Epinephrine for shock is typically administered as a continuous intravenous infusion at a starting dose of 0.05 to 0.1 mg (0.1 mg/mL, aka 1:10 000) when an IV line is in place, as recommended by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. The administration of epinephrine in shock requires careful consideration of the patient's hemodynamic status and close monitoring of blood pressure, heart rate, cardiac rhythm, and urine output.
- The dose of epinephrine can be repeated every 5 to 15 minutes as needed, with a recommended dose of 0.2 to 0.5 mg (1:1000) intramuscularly for anaphylaxis without cardiac arrest 1.
- In patients with anaphylactic shock, close hemodynamic monitoring is recommended, and immediate referral to a health professional with expertise in advanced airway placement, including surgical airway management, is advised 1.
- The use of epinephrine in septic shock is also guided by the Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016, which recommends norepinephrine as the first-choice vasopressor, with epinephrine added to and potentially substituted for norepinephrine when an additional agent is needed to maintain adequate blood pressure 1. The potential side effects of epinephrine include tachycardia, arrhythmias, hypertension, and tissue ischemia, and the infusion rate should be adjusted based on hemodynamic parameters to achieve the target mean arterial pressure of at least 65 mmHg.
- Epinephrine should be administered through a central line when possible, and the effective intervention associated with the least physiologic insult should be used, such as percutaneous rather than surgical drainage of an abscess 1.
From the Research
Epinephrine Dosage for Shock
- The dosage of epinephrine for shock is not explicitly stated in the provided studies, but its administration is recommended in various types of shock, including anaphylactic shock, cardiogenic shock, and distributive shock 2, 3, 4, 5.
- In anaphylactic shock, epinephrine is administered intramuscularly, into the anterolateral thigh, as soon as the diagnosis is suspected, and a continuous infusion of epinephrine should be started for patients unresponsive to repeated intramuscular injections 4, 5.
- For patients in shock, intravenous epinephrine should be used, either as a bolus or infusion, along with fluid resuscitation 5.
- High-dose intravenous epinephrine is required to reestablish cardiac function in severe anaphylactic shock, followed by continuous infusion of norepinephrine 3.
Considerations for Epinephrine Administration
- Epinephrine should be administered with caution in sulfite allergic patients due to its metabisulfite preservative 6.
- Antihistamines and corticosteroids are second-line medications and should never be given in lieu of, or prior to, epinephrine in anaphylactic shock 4.
- Aggressive fluid resuscitation should also be used to treat the intravascular volume depletion characteristic of anaphylaxis 4.