What is the recommended dose of epinephrine (adrenaline) for anaphylaxis?

Recommended Epinephrine Dosing for Anaphylaxis

The recommended dose of epinephrine for anaphylaxis is 0.01 mg/kg of 1:1000 (1 mg/mL) solution up to a maximum of 0.3 mg for children <30 kg, and 0.3-0.5 mg for adults and children ≥30 kg, administered intramuscularly into the anterolateral thigh. 1

Adult Dosing

• Adults and children ≥30 kg: 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution)
• Route: Intramuscular injection into the anterolateral thigh (vastus lateralis)
• May repeat every 5-10 minutes as necessary if symptoms persist 1, 2

Pediatric Dosing

• Children <30 kg: 0.01 mg/kg (0.01 mL/kg of 1:1000 solution) up to 0.3 mg maximum
• Route: Intramuscular injection into the anterolateral thigh (vastus lateralis)
• May repeat every 5-10 minutes as necessary if symptoms persist 1, 2

Autoinjector Selection Guidelines

For epinephrine autoinjectors (EAIs), the following weight-based recommendations apply:

• Children weighing 7.5-25 kg: 0.15 mg autoinjector 3
• Children weighing 25-30 kg: Consider switching from 0.15 mg to 0.3 mg autoinjector 3
• Children and adults ≥30 kg: 0.3 mg autoinjector 3, 2
• Adults and adolescents ≥45 kg: Consider 0.5 mg autoinjector based on shared decision making 4

Special Considerations

Infants (<7.5 kg)

For infants weighing less than 7.5 kg, the 0.15 mg autoinjector dose exceeds the recommended 0.01 mg/kg dose by more than twofold. However, after considering alternatives:

• Drawing up from ampules is error-prone and time-consuming (142 ± 13 seconds for parents) 3
• Dose preparation by laypersons can be highly inaccurate, sometimes containing no epinephrine at all 3
• Given the favorable benefit-to-risk ratio of epinephrine in anaphylaxis, many physicians recommend using the 0.15 mg autoinjector even in infants 3

Obese Patients

• Standard needle lengths in 0.3 mg autoinjectors may be too short to reach muscle in obese patients 5
• However, the need for subsequent epinephrine doses does not correlate with obesity or overweight status 3

Route of Administration

Intramuscular injection into the lateral thigh (vastus lateralis) is strongly preferred over subcutaneous injection:

• Time to maximum plasma concentration: 8 ± 2 minutes for IM injection vs. 34 ± 14 minutes for SC injection 3
• Higher and more rapid peak plasma concentrations with IM injection 3
• Intravenous administration should be reserved for severe cases unresponsive to IM epinephrine or for hospital settings due to risks of dilution errors and serious adverse effects 3, 1

Repeat Dosing

• 6-19% of pediatric patients require a second dose of epinephrine 3
• Indications for repeat dosing include:
  • Severe or rapidly progressive anaphylaxis
  • Failure to respond to initial injection
  • Delayed administration of initial dose
  • Inadequate initial dose 3

Safety Considerations

• Transient side effects may include pallor, tremor, anxiety, palpitations, headache, and nausea 3
• Serious adverse effects are rare with IM administration in appropriate doses 3
• There is no absolute contraindication to epinephrine in anaphylaxis 3, 1
• Use with caution in elderly patients and those with underlying cardiac disease, hyperthyroidism, Parkinson's disease, diabetes, and pheochromocytoma 1
• Consider potential drug interactions with sympathomimetics, cardiac glycosides, tricyclic antidepressants, MAO inhibitors, and beta-blockers 1, 2

Common Pitfalls to Avoid

1. Delayed administration: Early administration is critical as delayed use is associated with increased mortality 1
2. Incorrect route: Using subcutaneous instead of intramuscular route delays absorption 3
3. Incorrect site: Injecting into buttocks, digits, hands, or feet rather than the anterolateral thigh 2
4. Confusion about concentration: Always use 1:1000 (1 mg/mL) solution for IM/SC administration 1
5. Relying on antihistamines alone: Epinephrine is the first-line treatment; antihistamines and corticosteroids are secondary 1
6. Confusing cardiac arrest and anaphylaxis dosing: This can lead to potentially lethal complications 6