What is the protocol for administering intravenous (IV) epinephrine (EPI) in cases of anaphylaxis?

From the Guidelines

For anaphylaxis requiring intravenous epinephrine, administer 0.1-0.5 mg (100-500 mcg) of 1:10,000 epinephrine solution slowly over 5-10 minutes, as recommended by the most recent guidelines 1. In critical situations, a 50-100 mcg bolus can be given, followed by an infusion at 1-4 mcg/minute titrated to response. IV epinephrine should only be used when patients have not responded to intramuscular epinephrine or are in profound shock with inadequate circulation. Some key points to consider when administering IV epinephrine include:

• Continuous cardiac monitoring, frequent blood pressure checks, and pulse oximetry are essential during administration 1.
• The IV route provides immediate action but carries higher risks of cardiovascular complications including arrhythmias, hypertension, and myocardial ischemia.
• Epinephrine works by stimulating alpha-1 receptors (causing vasoconstriction), beta-1 receptors (increasing heart rate and contractility), and beta-2 receptors (causing bronchodilation and reducing mediator release from mast cells) 1. This combination of effects counteracts the life-threatening manifestations of anaphylaxis by improving blood pressure, cardiac output, and respiratory function. It is also important to note that antihistamines and glucocorticoids may be used as adjunctive therapy, but they should not be administered prior to, or in place of, epinephrine 1. Intravenous administration of H1 antihistamines may be used in a medical setting or by EMS, but it should never be utilized in place of timely intramuscular epinephrine administration 1. Glucocorticoids have a limited role in the acute management of anaphylaxis due to their slow onset of action and inability to reverse acute symptoms 1.

From the FDA Drug Label

1. DOSAGE & ADMINISTRATION 2.1 General Considerations Inspect visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if the solution is colored or cloudy, or if it contains particulate matter. Discard all unused drug.

The FDA drug label does not answer the question.

From the Research

Administration of Intravenous (IV) Epinephrine (EPI) in Anaphylaxis

• The protocol for administering IV EPI in cases of anaphylaxis is not well-established, as most studies recommend intramuscular (IM) epinephrine as the first-line treatment 2, 3, 4.
• However, one study compared the rates of cardiovascular adverse events and epinephrine overdoses associated with different routes of epinephrine administration, including IV bolus epinephrine, and found that the risk of overdose and adverse cardiovascular events is significantly higher with IV bolus epinephrine administration 5.
• The study found that all overdoses occurred when epinephrine was administered via IV bolus, and adverse cardiovascular events were associated with 10% of IV bolus epinephrine doses compared to 1.3% of IM epinephrine doses 5.
• Another study discussed the importance of epinephrine in the management of anaphylaxis, but did not specifically address the administration of IV EPI 6.
• The use of IV EPI in anaphylaxis is not recommended as a first-line treatment, and its administration should be approached with caution due to the higher risk of cardiovascular complications and overdose 5, 4.

Key Considerations

• IM epinephrine is the recommended first-line treatment for anaphylaxis 2, 3, 4.
• IV EPI administration is associated with a higher risk of cardiovascular complications and overdose compared to IM epinephrine 5.
• Patients at risk for anaphylaxis should carry two epinephrine autoinjectors and be taught how to use them 4.