What is the protocol for initiating an epinephrine (epi) drip for anaphylaxis?

From the Guidelines

For anaphylaxis requiring an epinephrine drip, the standard protocol involves administering intramuscular epinephrine while preparing the drip, then initiating the infusion at 0.1 mcg/kg/min, typically 5-15 mcg/min for adults, and titrating based on patient response. This approach is supported by the guidelines for the diagnosis and management of anaphylaxis 1. The epinephrine infusion is prepared by adding 1 mg of epinephrine to 250 mL of normal saline, creating a concentration of 4 mcg/mL.

Key Considerations for Epinephrine Drip Administration

• Continuous cardiac monitoring, frequent blood pressure checks, and pulse oximetry are essential during administration 1.
• The drip should be administered through a central line when possible, though a large-bore peripheral IV can be used initially.
• Epinephrine works by stimulating alpha-1 receptors to increase peripheral vascular resistance and blood pressure, while its beta-1 effects increase heart rate and contractility, and beta-2 effects cause bronchodilation to improve respiratory symptoms.
• Concurrent treatments should include IV fluids for volume resuscitation, H1 and H2 antihistamines, and corticosteroids, as outlined in the management guidelines 1.

Additional Therapeutic Considerations

• For bronchospasm resistant to epinephrine, consider using nebulized albuterol, 2.5-5 mg in 3 mL of saline, and repeat as necessary 1.
• For hypotension refractory to volume replacement and epinephrine injections, consider dopamine infusion, with continuous hemodynamic monitoring 1.
• Systemic glucocorticosteroids may be considered for patients with a history of idiopathic anaphylaxis or asthma and those who experience severe or prolonged anaphylaxis 1.

From the Research

Epinephrine Drip for Anaphylaxis

• The protocol for initiating an epinephrine (epi) drip for anaphylaxis involves administering epinephrine promptly once anaphylaxis is suspected, to minimize morbidity and mortality 2.
• The standard approved dose of epinephrine is 0.3-0.5 mg, injected intramuscularly in the anterolateral aspect of the mid-thigh for adults, and 0.01 mg/kg for children 3, 4, 5.
• The administration of epinephrine should be immediate upon evidence of the occurrence of anaphylaxis, as delays in administration may be fatal 4.
• There are no absolute contraindications to the administration of epinephrine for anaphylaxis, and the maximum single dose is 0.5 mg, which may be repeated after 5-10 minutes if needed 5.

Key Considerations

• Epinephrine is the cornerstone of anaphylaxis management and should be administered promptly to reverse symptoms and stabilize mast cells 2.
• Patients with known anaphylactic reactivity should be prescribed an epinephrine auto-injector to be carried at all times for treatment of potential recurrences 4.
• Education of patients and healthcare professionals on the proper use of epinephrine auto-injectors and management of anaphylaxis is paramount 2, 5.
• Strategies to improve education and access to appropriate drugs, such as labelled "anaphylaxis boxes" on resuscitation trolleys, may be necessary to ensure prompt and appropriate management of anaphylaxis 6.