Do we mix Adrenaline (Epinephrine) with Normal Saline for Anaphylaxis treatment?

Epinephrine Administration in Anaphylaxis

For anaphylaxis treatment, you should NOT mix 0.5ml of 1mg/ml adrenaline (1:1000) with 10ml normal saline for routine administration. Epinephrine should be administered intramuscularly as the first-line treatment, without dilution.

First-Line Treatment: Intramuscular Epinephrine

• Dose and Route: Administer epinephrine 0.01 mg/kg (maximum 0.5 mg in adults, 0.3 mg in children) intramuscularly into the anterolateral thigh 1
• Concentration: Use 1:1000 (1 mg/mL) solution for IM injection 1
• Timing: Repeat every 5-15 minutes if symptoms persist 1

When to Consider IV Epinephrine

Intravenous epinephrine (including diluted preparations) should ONLY be used in specific circumstances:

1. For patients with cardiac arrest due to anaphylaxis 2
2. For profoundly hypotensive patients who have failed to respond to:
   • Intravenous volume replacement AND
   • Several injected doses of epinephrine 2

IV Epinephrine Administration (Only if Indicated)

If IV epinephrine is deemed essential after failure of IM injections in a profoundly hypotensive patient:

• Option 1: Aqueous epinephrine 1:1000,0.1 to 0.3 mL in 10 mL of normal saline, administered intravenously over several minutes 2
• Option 2: Epinephrine infusion prepared by adding 1 mg (1 mL) of 1:1000 dilution to 250 mL of D5W (concentration 4.0 μg/mL), infused at 1-4 μg/min 2
• Option 3: Alternative 1:100,000 solution (1 mg in 100 mL saline) administered at 30-100 mL/h (5-15 μg/min) 2

Critical Safety Considerations

• WARNING: IV epinephrine carries risk of potentially lethal arrhythmias 2
• Monitoring: Continuous hemodynamic monitoring is essential when administering IV epinephrine 2
• Setting: IV epinephrine is best administered in settings with appropriate monitoring (emergency department or intensive care) 2

Additional Management Steps

1. Position: Place patient in recumbent position with elevated lower extremities 2
2. Airway: Establish and maintain airway; consider endotracheal intubation if necessary 2
3. Oxygen: Administer oxygen to patients with prolonged reactions, pre-existing hypoxemia, or requiring multiple epinephrine doses 2
4. Fluids: Establish IV access with normal saline; administer 1-2 L to adults at 5-10 mL/kg in first 5 minutes 2
5. Adjunctive medications: Consider diphenhydramine (25-50 mg) and ranitidine (50 mg in adults) as second-line therapy 2

Common Pitfalls to Avoid

• Delay in epinephrine administration: Failure to inject epinephrine promptly contributes to anaphylaxis fatalities 3
• Inappropriate route: Subcutaneous injection delays onset of action; IV injection increases risk of adverse effects 3
• Reliance on antihistamines alone: Antihistamines should never be administered alone in anaphylaxis treatment 2
• Inadequate monitoring: Patients require close monitoring due to potential for rapid changes in cardiovascular and respiratory status 2

Remember that epinephrine is the cornerstone of anaphylaxis management, and its administration should be immediate upon recognition of anaphylactic symptoms 4. No other medication has similar life-saving effects in multiple organ systems 3.