Do we mix 0.5ml of 1mg/ml Adrenaline (Epinephrine) (1:1000) with Normal Saline for Anaphylaxis treatment?

Anaphylaxis Treatment: Epinephrine Administration

For anaphylaxis treatment, do NOT mix 0.5ml of 1mg/ml Adrenaline (Epinephrine) (1:1000) with 10 ml Normal saline. Instead, administer 0.3-0.5mg of epinephrine (0.3-0.5ml of 1:1000 solution) intramuscularly into the anterolateral thigh as the first-line treatment. 1

Correct Administration Route and Dosage

First-Line Treatment:

• Intramuscular (IM) injection is the preferred route for initial anaphylaxis treatment 2, 1
• Dose: 0.01 mg/kg of 1:1000 solution, up to 0.5 mg in adults and 0.3 mg in children 2
• Location: Anterolateral thigh (vastus lateralis muscle) 2
• Timing: Can be repeated every 5-15 minutes if symptoms persist 2, 1

When to Consider IV Epinephrine:

IV epinephrine should be reserved for:

• Cardiac arrest from anaphylaxis
• Profound hypotension unresponsive to IM epinephrine and fluid resuscitation 2, 1

IV Epinephrine Preparation (if needed)

For patients with anaphylaxis not responding to IM epinephrine and volume resuscitation, IV epinephrine may be considered, but requires careful monitoring:

Option 1:

• Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL of D5W (concentration: 4.0 μg/mL)
• Infuse at 1-4 μg/min (15-60 drops/min with microdrop apparatus)
• Maximum rate: 10.0 μg/min 2, 1

Option 2:

• Prepare 1:100,000 solution: 1 mg (1 mL) in 100 mL of saline
• Initial rate: 30-100 mL/h (5-15 μg/min)
• Titrate based on clinical response 2

Additional Management Steps

1. Position: Place patient in recumbent position with elevated lower extremities if tolerated 2
2. Airway management: Establish and maintain airway; administer oxygen 2
3. IV fluids: Consider normal saline IV line for fluid replacement (1-2 L in adults at 5-10 mL/kg in first 5 minutes) 2
4. Monitoring: Continuous cardiac monitoring, frequent BP measurements, and pulse oximetry for patients receiving epinephrine 1

Important Cautions

• There are no absolute contraindications to epinephrine use in anaphylaxis 2, 1
• Antihistamines should NOT be administered before or in place of epinephrine 1, 3
• IV epinephrine carries significant risk of potentially lethal arrhythmias and should only be used when absolutely necessary 2, 1
• Mixing epinephrine with saline for nebulization may be considered for laryngeal edema but is NOT the first-line treatment for systemic anaphylaxis 2

Observation After Treatment

• All patients who receive epinephrine should be transported to an emergency department 1
• Extended observation is recommended for patients with severe anaphylaxis or those requiring multiple epinephrine doses 2, 1
• Patients requiring >1 dose of epinephrine are at higher risk for biphasic anaphylaxis 1

The most recent guidelines emphasize that intramuscular epinephrine is the cornerstone of anaphylaxis treatment, and diluting epinephrine with normal saline is not the recommended approach for initial management. The mixing of epinephrine with saline is primarily reserved for specific situations like IV infusions in refractory cases or specialized airway interventions, not routine anaphylaxis management.