What is the recommended dose of adrenaline (epinephrine) for infusion and bolus in pediatric patients?

Pediatric Adrenaline (Epinephrine) Dosing for Infusion and Bolus

For pediatric patients, the recommended adrenaline (epinephrine) bolus dose is 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) intravenously, with a maximum single dose of 0.3 mg for children under 30 kg, while continuous infusions should be prepared at a concentration of 0.1 mg/kg in 100 mL of saline (1 μg/kg/mL) and administered at 0.1-1.0 μg/kg/min. 1

Bolus Administration

Intravenous/Intraosseous Route

• First-line dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) 1
• Maximum single dose:
  • Children <30 kg: 0.3 mg (0.3 mL) 2
  • Children ≥30 kg: 0.5 mg (0.5 mL) 2
• Frequency: May repeat every 5 minutes as necessary 1, 2
• Administration: Give as slow IV push

Intramuscular Route (for anaphylaxis)

• >12 years: 500 μg (0.5 mL of 1:1000 solution) or 300 μg if child is small
• 6-12 years: 300 μg (0.3 mL of 1:1000 solution)
• <6 years: 150 μg (0.15 mL of 1:1000 solution) 1

Continuous Infusion

Standard Preparation Method

• Concentration: Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL D5W to yield 4 μg/mL 1
• Infusion rate: 1-4 μg/min (15-60 drops/min), increasing to maximum of 10 μg/min for adolescents 1

Alternative Preparation Method ("Rule of 6")

• Formula: 0.6 × weight (kg) = mg of epinephrine diluted to total 100 mL saline
• Resulting concentration: 1 mL/h delivers 0.1 μg/kg/min
• Infusion rate: Start at 0.1 μg/kg/min, titrate to effect (typical range 0.1-1.0 μg/kg/min) 1, 3

Alternative Concentration

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

Clinical Considerations

Indications for IV Epinephrine

• Cardiac arrest
• Profound hypotension unresponsive to volume replacement
• Anaphylactic shock 1

Monitoring Requirements

• Continuous cardiac monitoring
• Frequent blood pressure measurements
• Continuous pulse oximetry
• ECG monitoring when available 3

Cautions

1. Risk of arrhythmias: Epinephrine should be administered IV only during cardiac arrest or profound hypotension unresponsive to volume replacement and IM doses 1
2. Extravasation risk: Central venous access preferred for infusions; if peripheral, monitor site closely 3
3. Dosing errors: Great care should be taken to avoid decimal point errors when preparing dilutions 1
4. Beta-blocker therapy: May require higher doses; consider glucagon (1-5 mg IV) if poor response 3

Potential Adverse Effects

• Tachyarrhythmias
• Increased myocardial oxygen consumption
• Lactic acidosis
• Hyperglycemia
• Tissue necrosis if extravasation occurs 3

Special Situations

Anaphylaxis

• Start with IM dose if IV access not immediately available
• Consider IV infusion if multiple bolus doses required 1, 4
• Patients requiring >1 dose of adrenaline and/or fluid bolus are at increased risk of biphasic reactions (32% positive predictive value) 4

Cardiac Arrest

• Standard dose (0.01 mg/kg) may be inadequate in prolonged arrest
• Consider higher doses (0.1-0.2 mg/kg) if standard dose ineffective 5
• Endotracheal administration is less reliable than IV/IO but can be used if no vascular access 6

Neonatal Resuscitation

• IV route preferred over endotracheal route when possible
• Same dose as older children: 0.01-0.03 mg/kg 6

By following these dosing guidelines and monitoring protocols, clinicians can optimize the safety and efficacy of adrenaline administration in pediatric patients requiring emergency intervention.