Pediatric Epinephrine Infusion Dosing
For pediatric patients requiring continuous epinephrine infusion for shock after volume resuscitation, start at 0.1 µg/kg/min and titrate up to 1.0 µg/kg/min based on clinical response, with doses as high as 5 µg/kg/min sometimes necessary.
Recommended Dosing Range
The standard pediatric epinephrine infusion range is 0.1-1.0 µg/kg/min 1. This represents the most widely accepted dosing for continued shock after volume resuscitation in pediatric patients. Start at the lowest dose (0.1 µg/kg/min) and titrate upward to achieve desired hemodynamic effect.
Higher Doses When Needed
In refractory cases, doses may be escalated to 5 µg/kg/min 1. This higher range should be reserved for patients who fail to respond adequately to standard dosing and require more aggressive hemodynamic support.
Preparation Methods
Standard Infusion Preparation
For general use, prepare the infusion using the "Rule of 6" method 2:
- 0.6 × body weight (kg) = number of milligrams of epinephrine
- Dilute to a total volume of 100 mL normal saline
- At this concentration, 1 mL/h delivers 0.1 µg/kg/min
This method simplifies titration at the bedside and reduces dosing errors.
Alternative Preparation
Alternatively, dilute 1 mg (1 mL of 1:1000) epinephrine in 100 mL of normal saline to create a 1:100,000 solution (10 µg/mL), then calculate infusion rate based on patient weight 2.
Critical Safety Considerations
When to Use IV Epinephrine Infusion
Epinephrine infusions should only be initiated after:
- Failure to respond to IV volume replacement
- Failure to respond to several injected doses of epinephrine (for anaphylaxis)
- Profound hypotension or cardiac arrest 2
Monitoring Requirements
Continuous hemodynamic monitoring is essential when administering IV epinephrine infusions 2. This includes:
- Continuous cardiac monitoring (ECG)
- Blood pressure monitoring every minute initially
- Pulse oximetry
- Ideally, invasive arterial blood pressure monitoring in ICU settings
Major Risks
- Potentially lethal arrhythmias - the primary concern limiting IV epinephrine use 2
- Severe skin injury from extravasation - infuse into a large vein; phentolamine (0.1-0.2 mg/kg up to 10 mg diluted in 10 mL normal saline) injected intradermally at extravasation site may counteract dermal vasoconstriction 1
- Hypertension, tachyarrhythmias, myocardial ischemia
Context-Specific Dosing
Anaphylaxis
For anaphylaxis specifically, the guidelines describe using the Rule of 6 preparation where 1 mL/h delivers 0.1 µg/kg/min 2. This is reserved for profoundly hypotensive patients who have failed multiple IM epinephrine injections and volume resuscitation.
Septic Shock (Adult FDA Guidance)
The FDA label for IV epinephrine in septic shock recommends 0.05-2 µg/kg/min for adults 3, though pediatric-specific FDA dosing is not provided. The pediatric guidelines from AAP remain the authoritative source for children.
Common Pitfalls to Avoid
- Using IV epinephrine too early - Always attempt IM epinephrine and volume resuscitation first in anaphylaxis
- Inadequate monitoring - Never administer without continuous cardiac monitoring
- Wrong concentration - Epinephrine comes in 1:1000 (1 mg/mL) and 1:10,000 (0.1 mg/mL); verify concentration before preparation
- Peripheral IV extravasation - Use large veins; avoid leg veins in patients with vascular disease
- Abrupt discontinuation - Wean gradually over 12-24 hours after hemodynamic stabilization 3