How do you set up an epinephrine drip?

From the Guidelines

To set up an epinephrine drip, first prepare a solution by adding 1 mg of epinephrine (1 mL of 1:1000 concentration) to 250 mL of D5W, creating a concentration of 4.0 mg/mL, and administer it intravenously at a rate of 1 to 4 mg/min, increasing to a maximum of 10.0 mg/min for adults and adolescents, as recommended by the most recent guidelines 1.

Key Considerations

• The solution can be prepared by adding 1 mg of epinephrine to 250 mL of D5W, yielding a concentration of 4.0 mg/mL, as suggested by 1 and 1.
• The initial rate of administration should be 1 to 4 mg/min, with the option to increase up to 10 mg/min for adults and adolescents, as stated in 1 and 1.
• For children, a dosage of 0.01 mg/kg (0.1 mL/kg of a 1:10,000 solution) is recommended, with a maximum dose of 0.3 mg, as indicated by 1 and 1.
• An alternative pediatric dosage can be calculated using the "rule of 6": 0.6 × body weight (in kilograms) = number of milligrams diluted to total 100 mL of saline, with 1 mL/h delivering 0.1 mg/kg/min, as mentioned in 1 and 1.
• It is essential to monitor the patient continuously for heart rate, blood pressure, cardiac rhythm, and signs of tissue ischemia, and to adjust the dose frequently based on the patient's condition, as emphasized by 1 and 1.

Administration and Monitoring

• The epinephrine drip should be administered through a central line when possible, due to the risk of tissue damage from extravasation, as noted in the example answer.
• An infusion pump should be used for precise control, and the patient should be monitored continuously for heart rate, blood pressure, cardiac rhythm, and signs of tissue ischemia, as recommended by 1 and 1.
• The dose should be titrated based on patient response and hemodynamic parameters, with higher doses potentially needed for cardiogenic shock or cardiac arrest, as stated in 1 and 1.

From the FDA Drug Label

2.2 Hypotension associated with Septic Shock Dilute 10 mL (1 mg) of epinephrine from the syringe in 1,000 mL of 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution to produce a 1 mcg per mL dilution. 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).

To set up an epinephrine drip, dilute 10 mL (1 mg) of epinephrine in 1,000 mL of 5 percent dextrose solution to produce a 1 mcg per mL dilution. The infusion rate should be 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve a desired mean arterial pressure (MAP) 2.

• Key considerations:
  • Administer into a large vein.
  • Avoid using a catheter tie-in technique and avoid the veins of the leg in elderly patients or those with occlusive vascular diseases.
  • Titrate the dosage periodically to achieve the desired blood pressure goal.
  • Wean incrementally over time after hemodynamic stabilization 2.

From the Research

Setting Up an Epinephrine Drip

To set up an epinephrine drip, several factors must be considered, including the patient's weight, the desired dose, and the administration route.

• The neonatal resuscitation program recommends a wide dose range of epinephrine for newborns who receive chest compressions, with an endotracheal tube (ET) dose of 0.05-0.1 mg/kg or intravenous (IV) dose of 0.01-0.03 mg/kg 3.
• For ET administration, preparing 0.1 mg/kg or 1 ml/kg of 1 mg/10 ml epinephrine in a 5 ml syringe is suggested, while for IV epinephrine, an initial dose of 0.02 mg/kg or 0.2 ml/kg of 1 mg/10 ml epinephrine in a 1 ml syringe is recommended 3.
• The use of a color-coded syringe may decrease errors in dose preparation 3.

Considerations for Dosing

• A survey of physicians practicing pediatric emergency medicine found that 72% of respondents used doses larger than the standard dose of epinephrine, with 16% using a dose 10 to 20 times larger at least half of the time 4.
• The American Heart Association recommends a standard dose of epinephrine of 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) for pediatric resuscitation 4.
• A meta-analysis of randomized trials found no difference in all-cause mortality between patients receiving continuous IV epinephrine infusion and those receiving other vasoactive drugs 5.

Monitoring Infusions

• The DripAssist device is a potential tool for monitoring intravenous infusions, particularly in austere environments where traditional methods may be limited 6.
• A pilot study found that the DripAssist device was easy to understand and set up, with most participants perceiving a benefit compared to IV pumps or gravity drips 6.