What is the recommended dosage and management for an epinephrine (adrenaline) drip in a patient with severe hypotension?

Epinephrine Drip for Severe Hypotension Management

For severe hypotension, an epinephrine drip should be prepared by adding 1 mg (1 mL) of epinephrine to 100 mL of normal saline, creating a 10 mcg/mL solution, with an initial infusion rate of 0.05-2 mcg/kg/min, titrated to achieve a target mean arterial pressure (MAP) of 65 mmHg. 1, 2

Preparation Options

Standard Preparation Method

• Add 1 mg (1 mL) of epinephrine to 100 mL of normal saline or D5W to create a 10 mcg/mL solution 1, 2
• Alternative preparation: Add 1 mg (1 mL) of epinephrine to 250 mL of D5W to create a 4 mcg/mL solution 3

Administration Route

• Administer through a large vein whenever possible 2
• Avoid catheter tie-in techniques which may cause stasis and increased local concentration of the drug 2
• Avoid veins of the leg in elderly patients or those with occlusive vascular diseases 2

Dosing Protocol

Initial Dosing

• Start at 0.05-0.5 mcg/kg/min 1, 2
• Titrate up to 2 mcg/kg/min based on blood pressure response 2
• For pediatric patients: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution; maximum 0.3 mg) 3
• Alternative pediatric dosing using "rule of 6": 0.6 × weight (kg) = mg diluted to 100 mL saline; then 1 mL/hr delivers 0.1 mcg/kg/min 3

Titration

• Adjust dosage every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min to achieve desired MAP of 65 mmHg 1, 2
• If inadequate response after 10 minutes, consider doubling the dose 1
• After hemodynamic stabilization, wean incrementally over 12-24 hours, decreasing doses every 30 minutes 2

Monitoring Requirements

Essential Monitoring

• Continuous electrocardiographic monitoring 3, 1
• Frequent blood pressure measurements (every minute if continuous monitoring unavailable) 3
• Continuous arterial blood pressure monitoring when available 1
• Assessment of tissue perfusion markers (lactate levels, urine output, capillary refill time) 1
• Vigilant monitoring of infusion site for extravasation 1

Management of Refractory Hypotension

Escalation Strategy

• If no response to epinephrine, consider:
  • Adding vasopressin (up to 0.03 U/min) as a second agent 1
  • Additional fluid administration (up to 20-30 mL/kg) 3, 1
  • For patients on beta-blockers: Consider IV glucagon (1-5 mg) 3, 1

Special Situations

• For patients with cardiac arrest during anaphylaxis:
  • Higher doses may be required: 1-3 mg (1:10,000 dilution) IV over 3 minutes, followed by 3-5 mg IV over 3 minutes, then 4-10 mg/min infusion 3
  • For children with cardiac arrest: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) every 3-5 minutes 3

Complications and Management

Potential Complications

• Acute severe hypertension 1, 2
• Pulmonary edema (potentially fatal) 1
• Cardiac arrhythmias and myocardial ischemia (particularly in patients with underlying heart disease) 1, 2
• Tissue necrosis from extravasation 1, 2
• Oliguria or renal impairment 1

Management of Complications

• For extravasation: Infiltrate 5-10 mg phentolamine diluted in 10-15 mL saline into the affected site 1
• For arrhythmias: Consider reducing infusion rate and treating the specific arrhythmia 1
• Avoid mixing epinephrine with alkaline solutions like sodium bicarbonate (causes inactivation) 1

Important Cautions

• Epinephrine should be used with caution in patients with ischemic heart disease 1, 2
• Avoid in patients with mesenteric or peripheral vascular thrombosis 1
• Correct hypovolemia before administering epinephrine 1
• Drug interactions to monitor: alpha blockers, vasodilators, beta blockers, tricyclic antidepressants, MAO inhibitors 2

By following this protocol for epinephrine administration in severe hypotension, clinicians can optimize outcomes while minimizing potential complications. Continuous monitoring and appropriate titration are essential components of successful management.