What is the recommended epinephrine (adrenaline) dosage for treating shock?

Epinephrine Dosage for Shock

For shock treatment, epinephrine should be administered as an IV infusion at 0.05-1.0 μg/kg/min, titrated to desired clinical effect, with doses up to 5 μg/kg/min sometimes necessary in refractory cases. 1

Route of Administration and Initial Dosing

Anaphylactic Shock

• First-line approach: Intramuscular (IM) epinephrine in the anterolateral thigh

  • Adult dose: 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution)
  • Children ≥30 kg: 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution)
  • Children <30 kg: 0.01 mg/kg (0.01 mL/kg), maximum 0.3 mg
  • May repeat every 5-15 minutes as needed 2, 1

• When IV access is available:

  • IV bolus: 0.05-0.1 mg (0.5-1 mL of 1:10,000 solution)
  • This is approximately 5-10% of the cardiac arrest dose 2, 1
  • Caution: IV bolus administration carries significantly higher risk of cardiovascular complications and overdose compared to IM administration 3

Septic Shock

• IV infusion: 0.05-2 μg/kg/min, titrated to achieve desired mean arterial pressure (MAP)
• Adjust dosage every 10-15 minutes in increments of 0.05-0.2 μg/kg/min 4

Cardiogenic/Distributive Shock

• IV infusion: 0.1-1.0 μg/kg/min, starting at lowest dose and titrating to desired clinical effect
• Doses up to 5 μg/kg/min may be necessary in refractory cases 2

Continuous Infusion Preparation

Method 1 (for anaphylaxis):

• Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL D5W
• Resulting concentration: 4.0 μg/mL
• Infusion rate: 1-4 μg/min (15-60 drops/min with microdrop apparatus)
• Maximum rate: 10 μg/min 2

Method 2 (for anaphylaxis):

• Add 1 mg (1 mL) of epinephrine to 100 mL saline (1:100,000 solution)
• Initial rate: 30-100 mL/h (5-15 μg/min)
• Titrate based on clinical response and side effects 2

Method 3 (for septic shock):

• Dilute 10 mL (1 mg) of epinephrine in 1,000 mL of 5% dextrose solution
• Resulting concentration: 1 μg/mL
• Infusion rate: 0.05-2 μg/kg/min 4

Special Considerations

Monitoring

• Continuous hemodynamic monitoring is essential during IV epinephrine administration
• Monitor for tachyarrhythmias, ectopic beats, hypertension, and hypotension 2
• In settings without hemodynamic monitoring, IV epinephrine should only be used if essential after failure of several epinephrine injections 2

Extravasation Risk

• Extravascular administration can result in severe skin injury
• If extravasation occurs, consider phentolamine (0.1-0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at the extravasation site 2

Refractory Shock

• For anaphylactic shock refractory to epinephrine and volume resuscitation, consider vasopressor infusion (e.g., dopamine 400 mg in 500 mL D5W at 2-20 μg/kg/min) 2
• For patients on β-blockers, consider glucagon (1-5 mg IV over 5 minutes, followed by infusion at 5-15 μg/min) 1

Evidence on Administration Methods

• Continuous infusion of epinephrine has been shown to be more effective than bolus treatment in improving hemodynamic recovery in anaphylactic shock, even at lower total doses 5
• IV bolus epinephrine carries an 8.7 times higher risk of adverse cardiovascular events and significantly higher risk of overdose compared to IM epinephrine 3

Fluid Resuscitation

• Aggressive fluid resuscitation with isotonic crystalloids is essential alongside epinephrine administration
• Up to 7 L of crystalloids may be necessary in anaphylactic shock due to increased vascular permeability 2, 1
• Adults: 1-2 L of normal saline at 5-10 mL/kg in first 5 minutes
• Children: up to 30 mL/kg in first hour 2

Remember that early administration of epinephrine is critical for preventing mortality in shock, particularly anaphylactic shock, and the route and dosage should be selected based on the severity of the condition and available access.