What are the guidelines for administering an adrenaline (epinephrine) infusion?

Guidelines for Administering an Adrenaline (Epinephrine) Infusion

Adrenaline (epinephrine) infusions should be administered only in cases of severe anaphylaxis that is refractory to intramuscular epinephrine or in cases of profound hypotension in septic shock, with careful monitoring of vital signs and titration based on clinical response.

Indications for Adrenaline Infusion

• Adrenaline infusions are indicated primarily in two critical scenarios:

  • Severe anaphylaxis unresponsive to intramuscular epinephrine injections 1
  • Hypotension associated with septic shock 1, 2

• Intravenous epinephrine should be administered only during cardiac arrest or to profoundly hypotensive patients who have failed to respond to intravenous volume replacement and several injected doses of epinephrine 1

Preparation of Adrenaline Infusion

For Anaphylaxis:

• Method 1: Add 1 mg (1 mL) of 1:1000 dilution of epinephrine to 250 mL of D5W to yield a concentration of 4.0 μg/mL 1

• Method 2: Prepare a 1:100,000 solution by adding 1 mg (1 mL) of epinephrine in 100 mL saline 1

For Septic Shock:

• Dilute 10 mL (1 mg) of epinephrine in 1,000 mL of 5% dextrose solution or 5% dextrose and sodium chloride solution to produce a 1 μg/mL dilution 2
• The diluted solutions can be stored for up to 4 hours at room temperature or 24 hours under refrigeration 2

Dosing and Administration

For Anaphylaxis:

• Method 1: Infuse at a rate of 1 to 4 μg/min (15 to 60 drops per minute with a microdrop apparatus), increasing to a maximum of 10.0 μg/min for adults and adolescents 1

• Method 2: Administer intravenously at an initial rate of 30 to 100 mL/h (5-15 μg/min), titrated up or down depending on clinical response or epinephrine side effects 1

• For children: 0.01 mg/kg (0.1 mL/kg of a 1:10,000 solution; maximum dose, 0.3 mg) 1

• Alternative pediatric dosing by "rule of 6": 0.6 × body weight (kg) = number of milligrams diluted to total 100 mL of saline; then 1 mL/h delivers 0.1 μg/kg/min 1

For Septic Shock:

• Initial dosing infusion rate: 0.05 μg/kg/min to 2 μg/kg/min, titrated to achieve desired mean arterial pressure (MAP) 2

• Adjust dosage periodically (every 10-15 minutes) in increments of 0.05 μg/kg/min to 0.2 μg/kg/min to achieve blood pressure goals 2

• After hemodynamic stabilization, wean incrementally over time, decreasing doses every 30 minutes over a 12-24 hour period 2

Monitoring Requirements

• Continuous hemodynamic monitoring is essential when administering intravenous epinephrine 1

• In settings where continuous monitoring is not available, measure blood pressure and pulse every minute if intravenous epinephrine is deemed essential 1

• ECG monitoring should be performed if available 1

• For patients requiring dopamine or epinephrine, blood pressure should be measured frequently at intervals of 5-15 minutes 1

Route of Administration

• Whenever possible, give infusions of epinephrine into a large vein 2

• Avoid using a catheter tie-in technique, as obstruction to blood flow around the tubing may cause stasis and increased local concentration of the drug 2

• Avoid the veins of the leg in elderly patients or in those suffering from occlusive vascular diseases 2

Special Considerations and Precautions

• There is no absolute contraindication to epinephrine administration in anaphylaxis, but several anaphylaxis fatalities have been attributed to injudicious use of intravenous epinephrine 1

• In patients receiving beta-blockers who develop anaphylaxis, consider glucagon 1-5 mg IV infusion over 5 minutes if hypotension persists despite epinephrine 1

• If hypotension persists despite epinephrine infusion, consider alternative vasopressors such as dopamine (400 mg in 500 mL, at a rate 2-20 μg/kg/min) or vasopressin (25 U in 250 mL of 5% DW or NS at 0.01-0.04 U/min) 1

• Avoid administration in saline solution alone 2

Pediatric Considerations

• For intravenous administration in children in acute settings (operating theaters, ICU):
  • Prepare a syringe containing 1 mL of 1:10,000 adrenaline for each 10 kg body weight 1
  • Titrate to response, starting with one-tenth of the contents of the syringe 1
  • Great care should be taken to avoid dose errors when preparing dilutions 1

Common Pitfalls and Caveats

• Intravenous epinephrine carries significant risk of potentially lethal arrhythmias and should be used only when absolutely necessary 1

• Epinephrine has a short half-life, requiring continuous infusion rather than bolus administration for sustained effect 1

• Extravasation can cause substantial skin necrosis; frequently check the infusion site 1

• Endotracheal administration of epinephrine is likely to be ineffective and should be avoided when possible 3

• The standard 1 mg dose administered intravenously every 5 minutes remains the standard in cardiopulmonary resuscitation, with no proven benefit of higher doses 4