What is the management for anaphylactic shock with only epinephrine (adrenaline) 1:10,000 available for intravenous (IV) administration?

From the Guidelines

For anaphylactic shock, if you only have epinephrine 1:10,000 available for IV use, administer 0.1 mg (1 mL) IV slowly over 5 minutes, as recommended by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. This can be repeated every 5-15 minutes as needed based on patient response. The preferred route for epinephrine in anaphylaxis is actually intramuscular (IM) using 1:1,000 concentration (0.3-0.5 mg), but in severe shock with IV access already established, the IV route may be necessary. Be aware that IV epinephrine carries higher risks of cardiovascular complications including arrhythmias, so careful monitoring is essential, as emphasized in the guidelines 1. The 1:10,000 concentration is more dilute than the standard 1:1,000 used for IM injection, making it safer for IV administration. Epinephrine works by stimulating alpha-1 receptors to increase peripheral vascular resistance, reducing mucosal edema, and stimulating beta-1 and beta-2 receptors to increase heart rate, contractility, and bronchodilation. While administering epinephrine, ensure the patient is receiving:

• Supplemental oxygen
• IV fluids for volume resuscitation
• Prepare second-line medications such as antihistamines and corticosteroids, as suggested in the guidelines for anaphylaxis management 1. Key considerations include:
• Close hemodynamic monitoring for patients with anaphylactic shock 1
• Immediate referral to a health professional with expertise in advanced airway placement, including surgical airway management, due to the potential for rapid development of oropharyngeal or laryngeal edema 1
• The potential need for vasopressor infusion, such as dopamine, for hypotension refractory to volume replacement and epinephrine injections 1
• The consideration of glucagon infusion when concomitant β-adrenergic blocking agent complicates treatment 1
• The administration of systemic glucocorticosteroids for patients with a history of idiopathic anaphylaxis or asthma and patients who experience severe or prolonged anaphylaxis 1

From the FDA Drug Label

1. DOSAGE & ADMINISTRATION 2.1 General Considerations Inspect visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if the solution is colored or cloudy, or if it contains particulate matter. Discard all unused drug.

The management for anaphylactic shock with only epinephrine (adrenaline) 1:10,000 available for intravenous (IV) administration is not directly addressed in the provided drug label.

• Key point: The label provides dosing information for hypotension associated with septic shock, but not specifically for anaphylactic shock.
• Important consideration: The label does recommend diluting epinephrine to a 1 mcg per mL dilution for administration in certain cases, but it does not provide guidance on the use of undiluted 1:10,000 epinephrine for anaphylactic shock. 2

From the Research

Management of Anaphylactic Shock

• The primary treatment for anaphylactic shock is epinephrine (adrenaline) administration 3, 4, 5, 6, 7.
• According to the available evidence, epinephrine should be administered intramuscularly as soon as the diagnosis is suspected 3, 4, 5, 6, 7.
• However, if only epinephrine 1:10,000 is available for intravenous (IV) administration, it can be used in patients who are unresponsive to repeated intramuscular injections or in cases of cardiac arrest 3, 7.
• IV epinephrine should be administered with caution and ideally as a continuous infusion, as bolus doses can be associated with increased risk of adverse effects 6, 7.
• In addition to epinephrine, aggressive fluid resuscitation should be used to treat intravascular volume depletion characteristic of anaphylaxis 3, 5, 7.
• Other treatments, such as antihistamines and corticosteroids, may be considered as adjunctive therapy, but should not delay the administration of epinephrine 3, 4, 5, 6, 7.

Key Considerations

• Early recognition and treatment of anaphylaxis are critical to prevent morbidity and mortality 3, 4, 5, 6, 7.
• Patients with anaphylaxis should be monitored for a period of time after resolution of signs and symptoms, as biphasic reactions can occur 4, 5, 6, 7.
• The management of anaphylaxis should be individualized, taking into account the severity of symptoms, underlying medical conditions, and other factors 3, 4, 5, 6, 7.