What is the recommended dose of epinephrine (adrenaline) for treating hypotension, including both bolus and infusion doses?

Epinephrine Dosing for Hypotension

For hypotension associated with septic shock, initiate epinephrine as a continuous infusion at 0.05-2 mcg/kg/min, titrated to achieve a mean arterial pressure (MAP) of 65 mmHg or higher; for acute perioperative anaphylaxis with moderate hypotension, administer 20 mcg IV bolus, escalating to 50 mcg at 2 minutes if unresponsive, while for life-threatening hypotension or cardiac arrest, give 100 mcg or 1 mg boluses respectively. 1, 2

Continuous Infusion Dosing (Primary Method for Septic Shock)

Preparation and Initial Dosing

• Dilute 1 mg (10 mL) of epinephrine in 1,000 mL of 5% dextrose solution to produce a 1 mcg/mL concentration 1
• Start infusion at 0.05 mcg/kg/min and titrate up to 2 mcg/kg/min to achieve desired MAP 1
• Adjust dosage every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min until blood pressure goal is met 1
• Target MAP ≥65 mmHg for adequate tissue perfusion 1

Administration Route and Monitoring

• Infuse into a large vein whenever possible to minimize extravasation risk 1
• Avoid leg veins in elderly patients or those with occlusive vascular disease 1
• Do not use catheter tie-in technique as it may cause stasis and increased local drug concentration 1
• Continuous hemodynamic monitoring is essential during administration 2

Weaning Protocol

• After hemodynamic stabilization, wean incrementally over 12-24 hours by decreasing doses every 30 minutes 1

Bolus Dosing (For Perioperative Anaphylaxis)

Grade II Reactions (Moderate Hypotension/Bronchospasm)

• Initial dose: 20 mcg IV when vasopressor or bronchodilator is clinically indicated 2
• Escalation: 50 mcg at 2 minutes if unresponsive to initial dose 2
• If IV access is unavailable, administer 300 mcg IM 2

Grade III Reactions (Life-Threatening Hypotension/Bronchospasm)

• Initial dose: 50 mcg IV if no other vasopressors/bronchodilators have been given 2
• Alternative: 100 mcg IV where unresponsive to other vasopressors/bronchodilators 2
• Escalation: 200 mcg at 2 minutes if unresponsive to initial dose 2

Grade IV Reactions (Cardiac or Respiratory Arrest)

• Follow advanced life support guidelines with 1 mg (1,000 mcg) IV boluses 2
• Initiate cardiac compressions for inadequate cardiac output or systolic BP <50 mmHg 2

Refractory Hypotension Management (After 10 Minutes)

Escalation Strategies

• Double the bolus dose if inadequate sustained response 2
• Commence epinephrine infusion at 0.05-0.1 mcg/kg/min peripherally 2
• Start infusion when more than three epinephrine boluses have been administered 2
• Consider 500 mcg IM bolus while preparing infusion 2

Alternative Infusion Protocol for Anaphylaxis

• Prepare 1:100,000 solution (1 mg in 100 mL saline) 2
• Administer at initial rate of 30-100 mL/h (5-15 mcg/min) 2
• Titrate based on clinical response or epinephrine side effects 2
• Discontinue 30 minutes after resolution of all symptoms 2

Adjunctive Vasopressors for Persistent Hypotension

• Add norepinephrine infusion (0.05-0.5 mcg/kg/min), phenylephrine, or metaraminol 2
• Add vasopressin 1-2 IU bolus with or without infusion (2 units/h) 2
• Add IV glucagon (1-2 mg) in patients using beta-blockers 2

Prehospital/Emergency Bolus Dosing

Push-Dose Epinephrine Protocol

• Administer 10-20 mcg IV every 2 minutes until SBP ≥90 mmHg or MAP ≥65 mmHg 3, 4
• Research demonstrates median MAP increase of 11 mmHg with 20 mcg doses 4
• Effective in 58.5% of cases for resolving hypotension during transport 3
• Minimal adverse events: single episode of transient hypertension in 100 doses administered 3

Critical Precautions and Contraindications

Fluid Resuscitation Requirements

• Administer crystalloid 500 mL rapid bolus for Grade II reactions and repeat if inadequate response 2
• Administer 1 L crystalloid rapid bolus for Grade III reactions and repeat if inadequate response 2
• For septic shock, ensure minimum 30 mL/kg crystalloid bolus before or concurrent with epinephrine 2

Monitoring for Adverse Effects

• Watch for acute severe hypertension (SBP >180 mmHg) 1
• Monitor for potentially serious cardiac arrhythmias and myocardial ischemia, particularly in patients with underlying heart disease 1
• Risk of pulmonary edema, which may be fatal 1
• Potential for oliguria or renal impairment 1

Extravasation Management

• Avoid extravasation into tissues, which causes local necrosis 1
• If extravasation occurs, infiltrate 5-10 mg phentolamine diluted in 10-15 mL saline into the site immediately 2

Drug Interactions

• Do not mix with sodium bicarbonate or alkaline solutions in IV line, as epinephrine is inactivated 2
• Use cautiously with beta-blockers, tricyclic antidepressants, MAO inhibitors, and COMT inhibitors, which potentiate effects 1
• Alpha-blockers, vasodilators, and antihypertensives counter pressor effects 1

Common Pitfalls to Avoid

• Never delay epinephrine in anaphylaxis: Grade III/IV reactions require immediate administration, not stepwise escalation from lower doses 2
• Avoid using saline solution alone for epinephrine infusions; always use dextrose-containing solutions 1
• Do not underdose in life-threatening situations: 100 mcg or 1 mg boluses are appropriate for severe reactions, not the 20 mcg used for moderate hypotension 2
• Ensure adequate volume resuscitation: epinephrine without fluid replacement may worsen organ perfusion despite improved blood pressure 2
• Monitor for rebound hypotension: wean gradually over 12-24 hours rather than abrupt discontinuation 1