What is the recommended dose and frequency of epinephrine (adrenaline) administration in cardiac arrest?

From the Guidelines

The recommended dose of epinephrine (adrenaline) for cardiac arrest in adults is 1 mg (1:10,000 concentration) administered intravenously or intraosseously every 3-5 minutes during resuscitation efforts. This dose and frequency are based on the most recent and highest quality evidence available, including the 2023 American Heart Association focused update on adult advanced cardiovascular life support 1. The first dose should be given as soon as possible after cardiac arrest is recognized and vascular access is established. For pediatric patients, the dose is 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration), also repeated every 3-5 minutes as needed.

Epinephrine works by stimulating alpha-adrenergic receptors, causing peripheral vasoconstriction which increases coronary and cerebral perfusion pressure during chest compressions. This improved blood flow to the heart and brain is critical during resuscitation. The beta-adrenergic effects of epinephrine can increase myocardial oxygen demand and potentially cause dysrhythmias, but the alpha effects are considered more beneficial during cardiac arrest. High-quality CPR should be continued with minimal interruptions while administering epinephrine, as the medication's effectiveness depends on adequate circulation provided by chest compressions.

Some key points to consider when administering epinephrine during cardiac arrest include:

• The optimal timing for epinephrine in patients with shockable rhythms is unknown, but it is suggested to administer epinephrine after initial defibrillation attempts have been unsuccessful 1.
• The use of vasopressin alone or in combination with epinephrine does not improve outcomes in comparison with epinephrine alone for cardiac arrest 1.
• High-dose epinephrine is not recommended for routine use in cardiac arrest, as it has not been shown to improve survival to discharge or longer-term outcomes 1.

Overall, the administration of epinephrine during cardiac arrest is a critical component of resuscitation efforts, and the recommended dose and frequency should be followed to maximize the potential for successful resuscitation.

From the FDA Drug Label

2.2 Cardiac Arrest

In cardiac arrest, the American Heart Association recommends a dose of 1 mg intravenously every 3 to 5 minutes as needed. The recommended dose of epinephrine in cardiac arrest is 1 mg administered intravenously and repeated every 3 to 5 minutes as needed.

• Key points:
  • Dose: 1 mg
  • Route: intravenously
  • Frequency: every 3 to 5 minutes 2

From the Research

Epinephrine Dosing in Cardiac Arrest

• The recommended dose of epinephrine in cardiac arrest is not well established, with studies suggesting that the currently recommended dose may be too low 3.
• A study from 1991 suggests that a 5-mg dose of epinephrine may be required to increase diastolic blood pressure above 30 mm Hg, and recommends that all patients receive at least one 1-mg dose of epinephrine, with additional doses of 3-5 mg every five minutes or continuous infusions of 0.2-0.6 mg/min if the patient fails to respond 3.
• Another study from 2022 found that the epinephrine dosing interval was not associated with 1-month neurologically favorable survival after out-of-hospital cardiac arrest, with a median dosing interval of 3.5 minutes 4.
• A 1992 study compared standard-dose and high-dose epinephrine in cardiac arrest outside the hospital, and found no significant difference in outcome between the two groups, with 30% of patients in the standard-dose group and 33% in the high-dose group achieving return of spontaneous circulation 5.
• A 2023 systematic review and meta-analysis found that the epinephrine administration interval was not associated with better hospital outcomes, with no significant difference in favorable neurological outcome or survival to hospital discharge between different dosing intervals 6.
• A 2018 study found that 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 7.

Dosage and Frequency

• The American Heart Association recommends administering 1 mg of epinephrine every 3-5 minutes during cardiac arrest, but the optimal dose and frequency are not well established 4, 6.
• Studies have used a variety of dosing regimens, including 1 mg every 3-5 minutes, 0.5 mg every 2-8 minutes, and continuous infusions of 0.2-0.6 mg/min 3, 7.
• The choice of dosing regimen may depend on the individual patient's response to treatment, as well as the underlying cause of the cardiac arrest.

Key Findings

• The optimal dose and frequency of epinephrine administration in cardiac arrest are not well established, with different studies suggesting different dosing regimens 3, 4, 5, 6, 7.
• Further research is needed to determine the most effective dosing regimen for epinephrine in cardiac arrest, and to establish clear guidelines for its use in this setting 4, 6.