What is the recommended dose of adrenaline (epinephrine) for anaphylaxis?

Recommended Dose of Adrenaline (Epinephrine) for Anaphylaxis

The recommended dose of epinephrine for anaphylaxis in adults is 0.3 to 0.5 mg (1:1000 concentration) administered intramuscularly into the anterolateral aspect of the thigh, repeated every 5 to 15 minutes as needed. 1, 2

Adult Dosing

• For adults and children weighing ≥30 kg (66 lbs): 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000 concentration) intramuscularly into the anterolateral thigh 1, 2
• Repeat doses can be administered every 5 to 15 minutes as needed based on patient response 1
• Approximately 6-19% of patients require a second dose of epinephrine 1

Pediatric Dosing

• For children weighing <30 kg (66 lbs): 0.01 mg/kg (0.01 mL/kg of 1:1000 concentration) up to a maximum of 0.3 mg intramuscularly 3, 2
• For children weighing 7.5-25 kg: 0.15 mg epinephrine autoinjector is recommended 3
• For children weighing ≥25 kg: 0.3 mg epinephrine autoinjector is recommended 3
• For infants weighing <7.5 kg: The 0.15 mg dose exceeds the recommended 0.01 mg/kg dose, but is often still prescribed due to challenges with accurate dosing using ampule/syringe methods 3, 4

Route of Administration

• Intramuscular (IM) injection into the anterolateral thigh (vastus lateralis muscle) is the preferred route for first-line treatment 1, 5
• IM injection produces rapid peak plasma concentrations compared to subcutaneous administration 1, 6
• Intravenous (IV) epinephrine should be reserved for:
  • Patients in anaphylactic shock when an IV line is already in place (0.05 to 0.1 mg, which is 5-10% of the cardiac arrest dose) 1
  • Cardiac arrest or profound hypotension unresponsive to IM epinephrine and fluid resuscitation 3

Special Considerations

• There are no absolute contraindications to epinephrine use in anaphylaxis, even in elderly patients with comorbidities 1
• Common adverse effects include transient pallor, tremor, anxiety, and palpitations 1
• Serious adverse effects are rare when administered at appropriate doses via the IM route 1
• For patients requiring continuous treatment, consider adding 1 mg (1 mL of 1:1000) epinephrine to 1000 mL of 0.9% normal saline; starting at 2 μg/min (2 mL/min or 120 mL/h) and titrating up to 10 μg/min (10 mL/min or 600 mL/h) according to blood pressure, cardiac rate, and oxygenation 1

Common Pitfalls to Avoid

• Delaying epinephrine administration - this is the most critical error and may lead to increased mortality 6, 5
• Using subcutaneous instead of intramuscular route - IM administration provides faster absorption 1, 6
• Confusing anaphylaxis dosing with cardiac arrest dosing - the concentrations and doses differ significantly 7
• Withholding epinephrine due to fear of adverse effects - the benefits far outweigh the risks in anaphylaxis 1
• Using antihistamines or glucocorticoids as first-line treatment - these are adjunctive therapies only and should not delay epinephrine administration 1

Remember that epinephrine is the cornerstone of anaphylaxis management and should be administered promptly upon recognition of anaphylaxis symptoms 1, 6, 5.