What is the preparation method for a dirty epi (epinephrine) drip using 1 L NS (normal saline)?

How to Make a Dirty Epi Drip in the Emergency Department

To prepare a dirty epi drip using 1 L NS and 1 mg/10 mL epinephrine, add 1 mg (10 mL) of the 1:10,000 epinephrine solution to 1 L of normal saline to create a 1:1,000 concentration (1 mcg/mL). This preparation is a rapid method for creating a dilute epinephrine infusion for emergency treatment of shock in resource-limited settings 1.

Preparation Method

1. Gather supplies:

   • 1 L bag of normal saline (NS)
   • 1 mg/10 mL epinephrine (1:10,000 concentration)
   • IV tubing
   • Infusion pump (if available)

2. Preparation steps:

   • Take the 10 mL of 1:10,000 epinephrine (containing 1 mg)
   • Inject the entire 10 mL into the 1 L bag of normal saline
   • Mix thoroughly by gently inverting the bag several times
   • The resulting concentration is 1 mcg/mL (1 mg in 1000 mL = 1:1,000)

Administration Guidelines

• Initial infusion rate: 30-100 mL/hr (0.5-1.7 mcg/min) for adults 2

• Titrate based on:

  • Blood pressure response
  • Heart rate
  • Clinical improvement
  • Signs of epinephrine toxicity

• Maximum rate typically 10 mcg/min for adults 2

• For pediatric patients: 0.1 mcg/kg/min, titrated to effect 2

Clinical Monitoring During Infusion

• Continuous cardiac monitoring is essential
• Frequent blood pressure measurements (every 5 minutes initially)
• Continuous pulse oximetry
• Monitor for signs of epinephrine toxicity:
  • Tachycardia
  • Hypertension
  • Arrhythmias
  • Tremor
  • Anxiety
  • Pallor

Clinical Efficacy

This "dirty epi" approach has been shown to be effective in treating shock, particularly in resource-limited settings. A case series of 57 patients treated with dirty adrenaline in remote clinics showed improvement in systolic blood pressure from a median of 75.5 mmHg to 91 mmHg, with 86% survival to hospital discharge and no significant adverse events 1.

Important Considerations

• This preparation is typically used when more formal vasopressor preparations or infusion pumps are not immediately available

• If hemodynamic monitoring is available (e.g., in an emergency department), continuous monitoring is essential 2

• For severe shock not responding to this initial preparation, consider:

  1. Higher concentration epinephrine infusions
  2. Alternative vasopressors
  3. Additional fluid resuscitation

• For anaphylaxis specifically, intramuscular epinephrine (0.3-0.5 mg of 1:1,000 solution for adults) remains the first-line treatment before initiating an infusion 3

Alternative Preparation Methods

If a different concentration is needed, the Joint Task Force on Practice Parameters recommends:

• For higher concentration: Add 1 mg (1 mL) of 1:1,000 epinephrine to 250 mL D5W to yield a 4 mcg/mL solution (1:250,000) 2
• Alternative adult preparation: 1 mg (1 mL) in 100 mL saline for a 10 mcg/mL (1:100,000) solution 2

The dirty epi drip is a practical solution for emergency situations requiring immediate vasopressor support when more formal preparations are not immediately available or practical.