How to Start an Epinephrine Drip in a 70-kg Adult
For a 70-kg adult requiring an epinephrine infusion, prepare a 1:100,000 solution by adding 1 mg (1 mL) of 1:1000 epinephrine to 100 mL of normal saline, then start the infusion at 30-100 mL/h (5-15 mcg/min), titrating based on clinical response. 1
Critical Indication
Epinephrine infusions should only be used in profoundly hypotensive patients who have failed to respond to IV volume replacement and several injected doses of epinephrine, or during cardiac arrest. 1 The risk of potentially lethal arrhythmias makes this a high-stakes intervention that demands careful patient selection.
Preparation Methods
You have two guideline-endorsed options for preparing the infusion:
Option 1: Standard Dilution (Preferred with Infusion Pump)
- Add 1 mg (1 mL) of 1:1000 epinephrine to 100 mL of normal saline
- This creates a 1:100,000 solution (10 mcg/mL)
- Start at 30-100 mL/h (5-15 mcg/min) 1
- For your 70-kg patient: 7-35 mcg/min is the typical starting range 2
Option 2: Alternative Dilution (Without Infusion Pump)
- Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL of D5W
- This creates a 4.0 mcg/mL concentration
- Start at 1-4 mcg/min (15-60 drops/min with microdrop apparatus)
- Maximum rate: 10 mcg/min 1
Administration Protocol
Route: Infuse into a large vein whenever possible. 3 Avoid leg veins in elderly patients or those with occlusive vascular disease. 3
Starting Dose for Septic Shock: The FDA-approved dosing is 0.05-2 mcg/kg/min, titrated to achieve desired mean arterial pressure. 3 For your 70-kg patient, this translates to 3.5-140 mcg/min.
Titration: Adjust every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min to achieve blood pressure goals. 3 Titrate up or down based on clinical response or signs of epinephrine toxicity (arrhythmias, excessive tachycardia, myocardial ischemia). 1
Essential Monitoring Requirements
Continuous hemodynamic monitoring is essential when available (emergency department or ICU setting). 1 However, do not withhold epinephrine infusion if such monitoring is unavailable when clinically essential after failure of multiple epinephrine injections. 1
Minimum monitoring when continuous hemodynamic monitoring unavailable:
Critical Pitfalls to Avoid
Extravasation: Epinephrine causes tissue necrosis if it infiltrates. 2, 3 If extravasation occurs, immediately infiltrate the site with 5-10 mg of phentolamine diluted in 10-15 mL of saline to prevent tissue death. 2
Concentration Errors: Epinephrine comes in two concentrations—1:1000 (1 mg/mL) and 1:10,000 (0.1 mg/mL). 4 Use extreme caution to select the appropriate concentration. For infusions, you're starting with 1:1000 and diluting it further.
Premature Use: Do not start an epinephrine infusion before adequate fluid resuscitation. For anaphylaxis, adults should receive 1-2 L of normal saline at 5-10 mL/kg in the first 5 minutes before considering an infusion. 1
Drug Incompatibility: Do not mix epinephrine with sodium bicarbonate or other alkaline solutions—adrenergic agents are inactivated in alkaline environments. 2
Weaning Protocol
After hemodynamic stabilization, wean incrementally over 12-24 hours, decreasing doses every 30 minutes. 3 Abrupt discontinuation can cause rebound hypotension.
Context-Specific Considerations
For Anaphylaxis: Epinephrine infusion is reserved for cases not responding to IM epinephrine injections (0.3-0.5 mg every 5 minutes) and volume resuscitation. 1 The infusion is an escalation, not first-line therapy.
For Cardiac Arrest: During active resuscitation, high-dose IV epinephrine follows a different protocol: 1-3 mg (1:10,000 dilution) slowly over 3 minutes, then 3-5 mg over 3 minutes, followed by 4-10 mg/min infusion. 1
Storage: Diluted solutions can be stored for up to 4 hours at room temperature or 24 hours refrigerated. 3