What is the recommended dose of epinephrine (adrenaline) from a crash cart?

From the Guidelines

The recommended dose of epinephrine from a crash cart is 0.01 milligrams per kilogram (0.1 milliliter per kilogram of the 0.1 milligram per milliliter concentration) with a maximum dose of 1 milligram, administered intravenously or intraosseously every 3 to 5 minutes during resuscitation efforts, as stated in the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. This dose is applicable for pediatric patients, and for adults, the standard dose is 1 mg.

• The dose should be administered intravenously or intraosseously, with a repeat dose every 3 to 5 minutes.
• If no IV or IO access is available, epinephrine can be given via the endotracheal tube at a dose of 0.1 milligrams per kilogram (0.1 milliliter per kilogram of the 1 milligram per milliliter concentration) 1.
• The administration of epinephrine should be followed by a saline flush and elevation of the extremity to ensure rapid delivery to the central circulation.
• The use of epinephrine in cardiac arrest has been shown to increase the rate of return of spontaneous circulation (ROSC) and hospital admission, although its effect on long-term survival and neurological outcome is still being studied 1.
• The 2019 American Heart Association focused update on advanced cardiovascular life support recommends the use of standard-dose epinephrine (1 mg every 3-5 minutes) during adult CPR, as it has been shown to increase survival to hospital discharge and ROSC 1.

From the FDA Drug Label

1. DOSAGE & ADMINISTRATION 2.1 General Considerations ... To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).

The recommended dose of epinephrine from a crash cart is 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve a desired mean arterial pressure (MAP) 2.

• The dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min.
• Initial dose is not explicitly stated as a specific bolus dose for a crash cart, but rather as an infusion rate.

From the Research

Epinephrine Dose in Crash Cart

The recommended dose of epinephrine from a crash cart is typically 1 mg, administered intravenously every 3-5 minutes during cardiac arrest 3, 4, 5.

Key Points

• The optimal dose of epinephrine in humans during closed-chest CPR is unknown 3.
• Studies suggest that the dose of epinephrine currently recommended during CPR may be five to ten times lower than the dose required to produce the beneficial pharmacologic effects observed in animal models of closed-chest CPR 3.
• A 5-mg dose of epinephrine may be required to increase diastolic blood pressure above 30 mm Hg in patients with prehospital cardiac arrest 3.
• Reducing the dose of epinephrine administered during out-of-hospital cardiac arrest was not associated with a change in survival to hospital discharge or favorable neurological outcomes after OHCA 4.
• The timing of intravenous epinephrine administration is associated with outcomes after out-of-hospital cardiac arrest, with longer time to epinephrine administration significantly associated with a decreased chance of 1-month neurologically favorable survival 6.

Administration Considerations

• Epinephrine can be administered intravenously or endotracheally, but intravenous administration is generally more effective 7.
• The currently recommended doses of epinephrine administered endotracheally are rarely effective in the setting of cardiac arrest and CPR 7.