What is the recommended IV (intravenous) dose of epinephrine for anaphylaxis?

IV Epinephrine Dosing for Anaphylaxis

For anaphylaxis, the recommended IV epinephrine dose is 0.05-0.1 mg (using 1:10,000 solution) administered slowly over several minutes, and should only be used when patients have failed to respond to intramuscular epinephrine and volume resuscitation. 1

Indications for IV Epinephrine

IV epinephrine should be reserved for specific situations:

• Profound hypotension despite fluid resuscitation
• Anaphylaxis not responding to IM epinephrine and volume resuscitation
• Continued shock after volume resuscitation
• Cardiac arrest during anaphylaxis

Proper IV Administration Protocol

1. Preparation: Use 1:10,000 solution (0.1 mg/mL)
2. Initial dose: 0.05-0.1 mg administered slowly over several minutes
3. Alternative preparation method: Dilute 1 mg (1 mL) of 1:1000 epinephrine in 10 mL normal saline (yields 0.1 mg/mL) 2

Continuous Infusion Option

For ongoing anaphylaxis requiring sustained treatment:

• Standard preparation: Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL D5W (concentration: 4.0 μg/mL)
• Initial rate: 1-4 μg/min (15-60 drops/min with microdrop apparatus)
• Maximum rate: 10.0 μg/min
• Alternative preparation: 1:100,000 solution (1 mg in 100 mL saline) at 30-100 mL/h (5-15 μg/min) 2

Pediatric Dosing

• IV bolus: 0.01 mg/kg using 1:10,000 solution (maximum 0.3 mg) 2
• "Rule of 6" for infusion: 0.6 × body weight (kg) = mg of epinephrine diluted to 100 mL; then 1 mL/hr delivers 0.1 μg/kg/min 1

Critical Safety Considerations

• Continuous monitoring is essential: ECG, blood pressure (every minute during initial titration), and pulse oximetry 1
• High-risk setting: IV epinephrine carries significant risk of potentially lethal arrhythmias 2, 3
• Limited setting use: Only administer IV epinephrine without hemodynamic monitoring if deemed absolutely essential after failure of several epinephrine injections 2
• Overdose risk: IV bolus administration has 61.3 times higher risk of overdose compared to IM administration 3
• Cardiovascular complications: IV bolus carries 8.7 times higher risk of adverse cardiovascular events than IM administration 3

Cardiac Arrest During Anaphylaxis

For cardiopulmonary arrest during anaphylaxis, higher doses are used:

• 1-3 mg (1:10,000) slowly IV over 3 minutes
• Followed by 3-5 mg IV over 3 minutes
• Then 4-10 mg/min infusion 2

First-Line Treatment Reminder

Remember that IM epinephrine (0.3-0.5 mg of 1:1000 solution for adults, 0.01 mg/kg for children) in the lateral thigh is the first-line treatment for anaphylaxis 1, 4. IV administration should only be considered when:

• Patient has failed to respond to IM doses
• Patient has profound hypotension
• Patient is in cardiac arrest

Common Pitfalls to Avoid

• Dosing confusion: Mistaking cardiac arrest dosing (1 mg IV) for anaphylaxis dosing can cause severe complications 5
• Delayed administration: Delays in epinephrine administration increase mortality risk 6
• Route confusion: Using IV when IM would be more appropriate and safer 3
• Overreliance on antihistamines: These are second-line agents and should never replace epinephrine 2, 6
• Inadequate monitoring: Failing to monitor for cardiovascular complications during IV administration 1

Early and appropriate epinephrine administration is crucial for successful anaphylaxis management, but the route and dose must be carefully selected to maximize benefit while minimizing potentially serious cardiovascular risks.