Recommended Dose of Adrenaline (Epinephrine) Infusion in Neonates
For neonates requiring continuous epinephrine infusion after volume resuscitation, the recommended dose is 0.1-1.0 μg/kg per minute, starting at the lowest dose and titrating to the desired clinical effect. 1
Route of Administration and Dosing Guidelines
Intravenous (IV) Infusion
- Initial dose: 0.1 μg/kg/min
- Titration range: 0.1-1.0 μg/kg/min
- Maximum dose: Up to 5 μg/kg/min may be necessary in severe cases 1
- Concentration: Use 1:10,000 (0.1 mg/mL) solution for IV administration
Indications for Epinephrine Infusion
- Continued shock after adequate volume resuscitation
- Persistent hypotension unresponsive to fluid therapy
- Cardiogenic shock or heart failure requiring inotropic support
Bolus Dosing (For Comparison)
While the question specifically asks about infusion dosing, it's important to understand how this differs from bolus dosing used in resuscitation:
- IV bolus: 0.01-0.03 mg/kg (1:10,000 solution) 1, 2
- Endotracheal bolus (if IV access unavailable): 0.05-0.1 mg/kg (1:10,000 solution) 1, 2
- Repeat doses: Every 3-5 minutes if heart rate remains <60/min 1, 2
Administration Considerations
Safety Precautions
- Monitor for extravasation, as IV infiltration can cause 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 1
- Use infusion pumps for precise delivery
- Monitor vital signs continuously, especially blood pressure and heart rate
Potential Adverse Effects
- Tachyarrhythmias and ectopic beats
- Hypertension (especially with higher doses)
- Peripheral, renal, and splanchnic vasoconstriction at higher doses
- Decreased myocardial function with excessive doses 2
Evidence Quality and Recommendations
The recommendations for epinephrine infusion in neonates are based on very low-certainty evidence 1, 2. Most guidelines rely on extrapolation from adult and pediatric studies, animal models, and limited observational studies in neonates 3, 4.
The American Academy of Pediatrics and American Heart Association maintain these recommendations as the current standard of care despite the limited evidence base 2. Higher IV doses (>0.03 mg/kg for bolus or >1.0 μg/kg/min for infusion) are generally not recommended due to evidence of exaggerated hypertension, decreased myocardial function, and potential for worse neurological outcomes 2, 4.
Common Pitfalls to Avoid
- Dosing errors are common when preparing epinephrine for neonatal use 5
- Using adult concentrations (1:1,000) instead of the recommended neonatal concentration (1:10,000)
- Failing to titrate based on clinical response
- Delaying establishment of IV access when endotracheal administration is used
- Not monitoring for extravasation, which can cause severe tissue damage
- Administering high doses without adequate justification, which may worsen outcomes
Always verify the concentration and dose calculations before administration, particularly in emergency situations where errors are more likely to occur.