What is the dose for adrenaline (epinephrine) infusion?

Epinephrine (Adrenaline) Infusion Dosing Guidelines

For continuous epinephrine infusion, prepare 1 mg (1 mL) of 1:1000 epinephrine added to 1000 mL of 0.9% normal saline, starting at 2 μg/min (2 mL/min) and titrating up to 10 μg/min based on clinical response. 1

Preparation and Administration

Preparation:

• Add 1 mg (1 mL) of 1:1000 epinephrine to 1000 mL of 0.9% normal saline
• This creates a concentration of 1 μg/mL
• Clearly label the infusion to prevent medication errors

Initial Dosing:

• Start at 2 μg/min (2 mL/min)
• Titrate based on clinical response
• Maximum recommended rate: 10 μg/min

Clinical Context and Indications

Epinephrine infusions are primarily used in:

1. Anaphylaxis: When multiple bolus doses are required or for persistent symptoms
2. Severe hypotension: Unresponsive to initial bolus therapy
3. Persistent bronchospasm: As part of anaphylaxis management

Bolus Dosing Prior to Infusion

Before starting an infusion, initial bolus dosing is typically required:

For Anaphylaxis:

• Adults: 50 μg IV (0.5 mL of 1:10,000 solution) 2
• Children: 1 μg/kg IV (0.1 mL/kg of 1:10,000 solution) 2

Intramuscular Dosing (if IV access unavailable):

• Adults ≥30 kg: 0.3-0.5 mg IM (0.3-0.5 mL of 1:1000 solution) 1
• Children 15-30 kg: 0.15 mg IM (0.15 mL of 1:1000 solution) 1
• Children <10 kg: 0.01 mg/kg IM (up to 0.3 mg) 1

Monitoring Requirements

During epinephrine infusion:

• Continuous cardiac monitoring
• Frequent blood pressure measurements (every 3-5 minutes initially)
• Continuous pulse oximetry
• Monitor for signs of tachyarrhythmias or myocardial ischemia

Important Considerations and Pitfalls

1. Concentration errors: Double-check the concentration and dilution
2. Infusion rate calculation: Ensure proper programming of infusion pumps
3. Extravasation risk: Administer through a secure, large-bore IV in a large vein
4. Hemodynamic instability: Rapid titration may cause dangerous blood pressure fluctuations
5. Tachyarrhythmias: Monitor closely for cardiac adverse effects

Special Situations

Severe Cases with Cardiopulmonary Arrest:

Higher doses may be required:

• Initial: 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

Pediatric Considerations:

• Great care should be taken to avoid dose errors when preparing dilutions
• Further dilution may be needed in smaller children to allow precise dose titration 2

Remember that epinephrine has a short half-life, which is why continuous infusion may be necessary when multiple bolus doses are required for persistent symptoms. While there are no absolute contraindications to epinephrine use in anaphylaxis, careful monitoring is essential, particularly in elderly patients and those with cardiovascular disease.