What intravenous adrenaline (epinephrine) dose should be given to a peri‑arrest patient with shock?

IV Adrenaline Dose for Peri-Arrest Patient with Shock

For a peri-arrest patient with shock (patient with pulse but poor perfusion), administer IV epinephrine at 0.05 to 0.1 mg (50-100 mcg) as a slow bolus, or preferably as a continuous infusion at 0.05-2 mcg/kg/min, titrated to effect. This is fundamentally different from cardiac arrest dosing.

Critical Distinction: Peri-Arrest vs Cardiac Arrest

The term "peri-arrest" specifically refers to a patient who still has a pulse but is critically unstable and at imminent risk of cardiac arrest. This is NOT the same as cardiac arrest, and the dosing is dramatically different:

• Cardiac arrest (pulseless): 1 mg IV bolus every 3-5 minutes 1, 2
• Peri-arrest with shock (has pulse): 0.05-0.1 mg IV bolus OR continuous infusion 3

Recommended Dosing Strategy

For Anaphylactic Shock (Most Specific Guidance)

When IV access is established in anaphylactic shock with pulse:

• Initial IV bolus: 0.05-0.1 mg (50-100 mcg) given slowly 3
• Continuous infusion: 1-4 mcg/min initially, titrating up to maximum 10 mcg/min 4
• Alternative infusion preparation: 1 mg epinephrine in 100 mL saline (1:100,000 solution) at 30-100 mL/hr (5-15 mcg/min), titrated based on response 4

For Septic Shock (FDA-Approved Dosing)

For hemodynamic support in septic shock:

• Infusion rate: 0.05-2 mcg/kg/min, titrated to achieve desired MAP 5
• Dose adjustments: Every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min 5
• Weaning: Decrease incrementally every 30 minutes over 12-24 hours after stabilization 5

For Pediatric Peri-Arrest with Shock

In children with pulse but poor perfusion:

• IV/IO dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) 6
• Repeat: Every 3-5 minutes as needed 6
• Alternative infusion: 0.6 × body weight (kg) = mg diluted to 100 mL saline; then 1 mL/hr delivers 0.1 mcg/kg/min 4

Critical Safety Considerations

The 1 mg cardiac arrest dose is potentially lethal in a patient with a pulse. The guidelines explicitly warn that IV epinephrine should only be given at the 1 mg dose during cardiac arrest or to profoundly hypotensive patients who have failed multiple IM epinephrine injections and IV volume replacement 4. Several anaphylaxis fatalities have been attributed to injudicious use of IV epinephrine 4.

Monitoring Requirements

When administering IV epinephrine to a patient with a pulse:

• Continuous hemodynamic monitoring is essential 4, 3
• Monitor blood pressure and pulse every minute if continuous monitoring unavailable 4
• ECG monitoring to detect arrhythmias 4
• Risk of potentially lethal arrhythmias with excessive dosing 4

Practical Administration Algorithm

1. Confirm pulse present - If pulseless, use cardiac arrest protocol (1 mg every 3-5 min)

2. Establish large-bore IV access - Avoid leg veins in elderly or those with vascular disease 4

3. Choose route based on urgency and monitoring capability:

   • If immediate intervention needed: 0.05-0.1 mg slow IV push over several minutes 4, 3
   • If time permits setup: Continuous infusion preferred for better titration 3

4. Prepare infusion (if using):

   • Add 1 mg (1 mL of 1:1000) to 250 mL D5W = 4 mcg/mL concentration
   • Start at 1-4 mcg/min (15-60 drops/min with microdrop) 4
   • OR: 1 mg in 100 mL saline at 30-100 mL/hr 4

5. Titrate to effect:

   • Target: Adequate perfusion, MAP >65 mmHg, improved mental status
   • Increase gradually based on response
   • Maximum: 10 mcg/min in adults 4

6. Concurrent management:

   • Aggressive IV fluid resuscitation (1-2 L crystalloid in adults, up to 30 mL/kg in first hour for children) 4
   • Treat underlying cause
   • Consider adjunct vasopressors if refractory (dopamine 2-20 mcg/kg/min) 4

Common Pitfalls to Avoid

• Never give 1 mg boluses to a patient with a pulse - This is the cardiac arrest dose and risks fatal arrhythmias
• Don't use IM route if IV established - IV allows for better titration and faster response in shock 3
• Avoid rapid IV push - Give slowly over several minutes to prevent arrhythmias 4
• Don't delay fluid resuscitation - Volume replacement is mandatory and should occur simultaneously 4
• Don't use peripheral leg veins - Risk of stasis and increased local drug concentration 4, 5

The evidence consistently demonstrates that peri-arrest shock requires 10-20 times lower doses than cardiac arrest, with continuous infusion preferred over boluses when feasible for better hemodynamic control and safety 4, 3.