What is the recommended dose for a push dose of epinephrine (Epi)?

Push Dose Epinephrine Recommendations

For push dose epinephrine, the recommended dose is 10-20 μg (0.1-0.2 mL of 1:100,000 solution) administered intravenously every 2 minutes until the desired hemodynamic effect is achieved. 1

Preparation of Push Dose Epinephrine

• Prepare a 1:100,000 solution by diluting 1 mL of 1:10,000 epinephrine (0.1 mg/mL) in 9 mL of normal saline, resulting in a concentration of 10 μg/mL 1
• Alternatively, dilute 0.1-0.3 mL of 1:1000 epinephrine (1 mg/mL) in 10 mL of normal saline for intravenous administration over several minutes 2

Clinical Indications

• Push dose epinephrine is indicated for temporary management of hypotension not responding to initial fluid resuscitation 1
• Most commonly used in post-cardiac arrest, sepsis, altered mental status, and cardiogenic shock scenarios 1
• Should be administered intravenously only during cardiac arrest or to profoundly hypotensive patients who have failed to respond to intravenous volume replacement and several injected doses of epinephrine 2

Hemodynamic Effects

• Median increase in mean arterial pressure (MAP) is approximately 13 mmHg following administration 1
• Minimal effect on heart rate (median increase of 2 beats per minute) 1
• Resolution of hypotension occurs in approximately 58.5% of cases 1

Monitoring and Safety Considerations

• Continuous hemodynamic monitoring is essential when administering intravenous epinephrine 2
• In settings where continuous hemodynamic monitoring is unavailable, monitor blood pressure and pulse every minute and use electrocardiographic monitoring if available 2
• Adverse events are rare but may include transient extreme hypertension 1
• Because of the risk for potentially lethal arrhythmias, epinephrine should be administered intravenously with caution 2

Transition to Continuous Infusion

• If repeated push doses are required, consider transitioning to a continuous epinephrine infusion 2
• For continuous infusion, prepare by adding 1 mg (1 mL) of 1:1000 epinephrine to 250 mL of D5W to yield a concentration of 4.0 μg/mL 2
• Infuse at a rate of 1-4 μg/min (15-60 drops per minute with a microdrop apparatus), increasing to a maximum of 10.0 μg/min as needed 2
• Alternatively, prepare a 1:100,000 solution (1 mg in 100 mL of saline) and administer at 30-100 mL/h (5-15 μg/min), titrated based on clinical response 2

Special Considerations

• Higher cumulative doses of epinephrine during resuscitation have been associated with unfavorable neurologic outcomes 3, 4
• Use the minimum effective dose to achieve hemodynamic stability 3, 4
• Extravascular administration can result in severe skin injury; ensure proper intravenous access 2
• For pediatric patients, weight-based dosing should be used (0.01 mg/kg or 0.1 mL/kg of 1:10,000 solution; maximum dose 0.3 mg) 2

Push dose epinephrine serves as a bridge to more definitive therapy and should be used judiciously while preparing for continuous vasopressor infusions in patients with persistent hypotension 1.