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

Adrenaline Infusion Administration Guidelines

Indications for Continuous Infusion

Adrenaline infusions should be initiated when multiple bolus doses fail to maintain adequate blood pressure or when severe, refractory anaphylaxis or cardiac arrest requires sustained vasopressor support. 1, 2

• Start an adrenaline infusion if several bolus doses are required for severe hypotension or bronchospasm, as adrenaline has a short half-life requiring continuous administration 1, 2
• Intravenous epinephrine should only be used during cardiac arrest or in profoundly hypotensive patients who have failed intravenous volume replacement and multiple injected doses 2, 3
• Continuous hemodynamic monitoring is mandatory when administering intravenous epinephrine 2

Preparation and Dosing

Adult Dosing for Anaphylaxis

For anaphylaxis requiring infusion, prepare a 1:100,000 solution by adding 1 mg (1 mL) of epinephrine to 100 mL saline, starting at 1-4 μg/min and titrating up to a maximum of 10 μg/min. 2, 3

• Initial infusion rate: 1-4 μg/min (15-60 drops per minute with microdrop apparatus) 2
• Titrate based on clinical response and side effects 3
• Maximum rate: 10 μg/min for adults and adolescents 2
• Alternative preparation: Add 1 mg epinephrine to 250 mL D5W yielding 4 μg/mL concentration 3

Pediatric Dosing

For children requiring intravenous adrenaline in acute settings, prepare 1 mL of 1:10,000 adrenaline for each 10 kg body weight, starting with 1 μg/kg and titrating to response. 1, 2

• Prepare syringe: 1 mL of 1:10,000 adrenaline per 10 kg body weight (0.1 mL/kg of 1:10,000 = 10 μg/kg) 1
• Starting dose: One-tenth of syringe contents (1 μg/kg) 1, 2
• Children often respond to as little as 1 μg/kg 1
• Alternative dosing: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution; maximum 0.3 mg) 2, 3

Administration Route and Monitoring

Preferentially infuse adrenaline through a central venous catheter, but peripheral venous or intraosseous access may be used if central access is unavailable. 1, 2

• Central venous access is preferred to minimize extravasation risk 2
• If central catheters are unavailable or staff lacks experience, use a large-bore peripheral vein or intraosseous cannula 1
• Frequently check the infusion site for extravasation, as substantial skin necrosis may occur 1, 2
• Monitor blood pressure and heart rate every 5-15 minutes during infusion 1, 2

Cardiac Arrest Context

For cardiac arrest, the standard dose remains 1 mg intravenous adrenaline every 3-5 minutes, though high-dose regimens have not demonstrated improved survival or neurological outcomes in humans despite animal study success 1, 4

• Standard dose: 1 mg IV every 3-5 minutes during resuscitation 1, 4
• Initial bolus for anaphylaxis during anesthesia: 50 μg (0.5 mL of 1:10,000 solution) for adults, repeated as needed 1
• No evidence supports routine high-dose adrenaline in humans 1, 4

Critical Precautions and Pitfalls

Intravenous epinephrine carries significant risk of potentially lethal arrhythmias and should only be used when absolutely necessary with continuous monitoring. 2, 3

• Side effects occur in approximately 21% of patients, mostly mild (tremors, palpitations, anxiety) 5
• Potentially severe adverse effects (hypertension, chest discomfort, ECG changes) occur in only 3% of cases 5
• Intravenous administration is associated with more severe adverse events compared to intramuscular 5
• Avoid in patients with solvent abuse, cocaine, or other sympathomimetic drug toxicity 1
• Do not administer repeated injections at the same site due to vasoconstriction-induced tissue necrosis 6

Special Considerations for Beta-Blocker Patients

For patients on beta-blockers with persistent hypotension despite epinephrine, consider glucagon 1-5 mg IV infusion over 5 minutes 2

Alternative Vasopressors for Refractory Shock

If blood pressure does not recover despite adrenaline infusion, consider alternative vasopressors such as metaraminol or norepinephrine according to clinician experience 1

• Norepinephrine should be preferred over epinephrine when available in septic shock due to less lactic acidosis 1
• Combined use of dopamine and epinephrine is discouraged in children 1