What is the recommended epinephrine (adrenaline) concentration and dose for the treatment of anaphylaxis?

Epinephrine Concentration and Dosing for Anaphylaxis

For anaphylaxis, epinephrine should be administered intramuscularly at a concentration of 1:1000 (1 mg/mL) with a dose of 0.01 mg/kg (maximum 0.5 mg in adults and 0.3 mg in children) into the anterolateral thigh. 1

Standard Dosing Recommendations

Adults and Children ≥30 kg (66 lbs)

• Dose: 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution)
• Route: Intramuscular injection into anterolateral thigh
• Frequency: Can repeat every 5-15 minutes as necessary 1, 2

Children <30 kg (66 lbs)

• Dose: 0.01 mg/kg (0.01 mL/kg of 1:1000 solution), maximum 0.3 mg
• Route: Intramuscular injection into anterolateral thigh
• Frequency: Can repeat every 5-15 minutes as necessary 1, 2

Weight-Based Dosing Guide

• ≥30 kg (66 lbs): 0.3-0.5 mg
• 25-30 kg (55-66 lbs): 0.3 mg
• 10-25 kg (22-55 lbs): 0.15 mg
• <10 kg: 0.01 mg/kg (up to 0.3 mg) 3

Administration Considerations

1. Preferred Route: Intramuscular injection is preferred over subcutaneous for faster absorption 1
2. Injection Site: Anterolateral thigh (vastus lateralis muscle) provides optimal absorption 1
3. Auto-injector Options:
   • 0.3 mg for adults and children ≥30 kg
   • 0.15 mg for children 15-30 kg
   • 0.1 mg for infants (where available) 1

For Refractory Anaphylaxis

If the patient does not respond to initial intramuscular epinephrine injections, consider:

IV Epinephrine Preparation Options

• Use 1:10,000 solution (0.1 mg/mL) for IV administration 3
• Alternative preparation: Dilute 1 mg (1 mL) of 1:1000 epinephrine in 10 mL normal saline to yield 0.1 mg/mL 3
• For continuous infusion: Add 1 mg (1 mL) of 1:1000 epinephrine to 1000 mL of 0.9% normal saline; start at 2 μg/min (2 mL/min) and titrate up to 10 μg/min based on response 1

Cardiopulmonary Arrest During Anaphylaxis

For severe cases with cardiopulmonary arrest, higher doses may be required:

• Initial dose: 1-3 mg (1:10,000) slowly IV over 3 minutes
• Follow with: 3-5 mg IV over 3 minutes
• Then: 4-10 μg/min infusion 1, 3

Important Clinical Considerations

1. No Absolute Contraindications: There are no absolute contraindications to epinephrine use in anaphylaxis, even in elderly patients or those with cardiovascular disease 1, 3

2. Avoid Common Pitfalls:

   • Delayed administration: Prompt administration is critical to prevent fatal outcomes 4
   • Incorrect route: Intramuscular is preferred over subcutaneous 1
   • Incorrect site: Avoid injecting into buttocks, digits, hands, or feet 2
   • Overreliance on antihistamines: Antihistamines should never replace epinephrine as first-line treatment 5

3. Monitoring After Administration:

   • All patients should be transported to an emergency department for observation
   • Observation period of 4-6 hours is recommended after successful treatment 3
   • Monitor for potential adverse effects: anxiety, tremor, palpitations, dizziness, headache 2

Remember that epinephrine is the cornerstone of anaphylaxis management, and delays in administration can be fatal 6. Despite evidence supporting its use, epinephrine remains underutilized in clinical practice, with antihistamines often being incorrectly used as first-line treatment 5.