What are the guidelines for adrenaline (epinephrine) infusion in critical care situations in South Africa?

Adrenaline (Epinephrine) Infusion Guidelines in South Africa

For critical care situations in South Africa, adrenaline infusions should be prepared using a standard concentration of 1:100,000 (1 mg in 100 mL of saline) and administered at an initial rate of 30-100 mL/h (5-15 μg/min), titrating according to clinical response. 1

Preparation of Adrenaline Infusions

Standard Method (Recommended):

• Add 1 mg (1 mL) of 1:1000 adrenaline to 100 mL of normal saline
• This yields a concentration of 10 μg/mL (1:100,000 solution)
• Initial infusion rate: 30-100 mL/h (5-15 μg/min) 1

Alternative Method:

• Add 1 mg (1 mL) of 1:1000 adrenaline to 250 mL of D5W
• This yields a concentration of 4 μg/mL (1:250,000 solution)
• Initial infusion rate: 1-4 μg/min (15-60 drops/min with a microdrop apparatus) 2

Administration Guidelines

Initial Bolus (if needed before infusion):

• Adults: 50 μg IV (0.5 mL of 1:10,000 solution) 2
• May be repeated if severe hypotension or bronchospasm persists

Infusion Rates:

• Start at 5-15 μg/min and titrate to desired mean arterial pressure 1
• Increase by 1-2 μg/min every 5-10 minutes based on blood pressure response
• Maximum rate: 10 μg/min in most cases 2

For Septic Shock (specific indication):

• Dosing range: 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 3

Monitoring Requirements

• Continuous hemodynamic monitoring is essential
• Measure blood pressure every 1-5 minutes during initiation
• Use pulse oximetry and clinical assessment for signs of adequate perfusion
• Watch for signs of adrenaline toxicity:
  • Tachyarrhythmias
  • Hypertension
  • Myocardial ischemia
  • Tremor 1

Pediatric Dosing

• Preparation: 0.6 × weight (kg) = mg of adrenaline diluted to 100 mL
• Initial rate: 1 mL/h delivers 0.1 μg/kg/min
• Alternative method: Prepare 1 mL of 1:10,000 adrenaline for each 10 kg body weight
• Starting dose: 0.1 mL/kg of this solution (1 μg/kg) 2, 1

Weaning Protocol

• After hemodynamic stabilization, wean incrementally
• Decrease doses gradually every 30 minutes over a 12-24 hour period 3

Special Considerations and Precautions

• Administer into a large vein to minimize risk of extravasation
• Avoid catheter tie-in techniques which may cause stasis and increased local concentration
• Avoid veins of the leg in elderly patients or those with occlusive vascular diseases 3
• Use with extreme caution in patients with:
  • Ischemic heart disease
  • Hypertension
  • Arrhythmias
• Avoid in patients taking beta-blockers as this may precipitate severe hypertension 1

Management of Inadequate Response

• Ensure adequate volume status first (administer crystalloids at 5-10 mL/kg)
• If blood pressure does not recover despite adequate adrenaline infusion, consider alternative vasopressors according to training and experience 2, 1

Storage and Stability

• Diluted solutions can be stored for up to 4 hours at room temperature
• Or 24 hours under refrigerated conditions 3

Remember that adrenaline infusions should only be administered in settings with appropriate monitoring capabilities and by healthcare professionals trained in their use and management of potential complications.