What is the recommended dosing and management for push dose epinephrine (adrenaline) in a patient with hypotension?

Push Dose Epinephrine for Hypotension Management

For patients with hypotension, push dose epinephrine should be administered at 10-20 μg IV every 2 minutes until systolic blood pressure reaches at least 90 mmHg or mean arterial pressure (MAP) reaches at least 65 mmHg. 1

Preparation and Dosing

Standard Preparation Method:

• Take 1 mL (1 mg) of epinephrine 1:1000 and dilute in 9 mL of normal saline to create a 1:10,000 solution (100 μg/mL)
• This creates a push dose epinephrine solution of 10 μg per 0.1 mL

Dosing by Severity of Hypotension:

Grade II (Moderate Hypotension):

• Initial dose: 20 μg IV 2
• If unresponsive after 2 minutes: Administer 50 μg IV 2
• If IV access is not available: Administer 300 μg IM 2
• Fluid resuscitation: 500 mL crystalloid as rapid bolus (repeat if inadequate response) 2

Grade III (Life-threatening Hypotension):

• Initial dose: 50 μg IV if no other vasopressors have been given 2
• If unresponsive to other vasopressors: 100 μg IV 2
• If unresponsive after 2 minutes: Administer 200 μg IV 2
• Fluid resuscitation: 1 L crystalloid as rapid bolus (repeat if inadequate response) 2

Grade IV (Cardiac or Respiratory Arrest):

• Follow advanced life support guidelines: 1 mg IV epinephrine 2
• Initiate cardiac compressions for inadequate cardiac output or systolic BP <50 mmHg 2

Management Algorithm for Refractory Hypotension

If inadequate sustained response after 10 minutes:

1. Escalate epinephrine dose (double the bolus dose) 2
2. Consider starting epinephrine infusion (0.05-0.1 μg/kg/min) peripherally 2
3. Start epinephrine infusion if more than three epinephrine boluses have been administered 2
4. Escalate fluid administration up to 20-30 mL/kg 2

If persistent hypotension after 10 minutes:

1. Add an infusion of norepinephrine (0.05-0.5 μg/kg/min), phenylephrine, or metaraminol 2
2. Consider vasopressin as a bolus 1-2 IU with or without infusion (2 units/hr) 2
3. For patients on beta-blockers: Add IV glucagon (1-2 mg) 2

Continuous Infusion Preparation (if needed)

Option 1:

• Add 1 mg (1 mL) of epinephrine 1:1000 to 250 mL D5W to yield 4.0 μg/mL
• Infuse at 1-4 μg/min (15-60 drops/min with microdrop apparatus)
• Maximum rate: 10.0 μg/min 2

Option 2 (with infusion pump):

• Add 1 mg (1 mL) of epinephrine to 100 mL saline (1:100,000 solution)
• Initial rate: 30-100 mL/hr (5-15 μg/min)
• Titrate based on clinical response and side effects 2

For Septic Shock (FDA-labeled use):

• Dilute 1 mg epinephrine in 1,000 mL of D5W or D5NS to produce 1 μg/mL solution
• Initial dosing: 0.05 μg/kg/min to 2 μg/kg/min
• Adjust every 10-15 minutes in increments of 0.05-0.2 μg/kg/min to achieve desired MAP 3

Monitoring and Precautions

• Continuous hemodynamic monitoring is essential when available
• If monitoring is limited, check blood pressure and pulse every minute
• Use ECG monitoring when available 2
• Observe for potential adverse effects: tachyarrhythmias, extreme hypertension 1
• Avoid using in veins of the leg in elderly patients or those with occlusive vascular diseases 3
• Whenever possible, administer into a large vein 3

Special Considerations

• Push dose epinephrine has been shown to increase MAP by a median of 13 mmHg in critical care transport settings 1
• In pediatric patients, doses below 1 μg/kg may be less effective than doses between 1-5 μg/kg 4
• Push dose epinephrine can provide temporary stabilization while other therapies are being prepared or adjusted 4
• For patients with post-cardiac arrest hypotension unresponsive to IV fluids, bolus epinephrine may be considered 5

Push dose epinephrine serves as a bridge to more definitive management in hypotensive emergencies, allowing rapid correction of blood pressure while continuous infusions are being prepared or other interventions are initiated.