What is the recommended dosage for epinephrine (adrenaline) infusion?

From the Guidelines

Epinephrine infusion for anaphylaxis in adults should be initiated at a dose of 0.05 to 0.1 mg (0.1 mg/mL, aka 1:10 000) when an IV line is in place, as recommended by the 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.

Key Considerations

• The dose can be titrated based on patient response and hemodynamic monitoring.
• IV infusion of epinephrine is a reasonable alternative to IV boluses for treatment of anaphylaxis in patients not in cardiac arrest.
• Close monitoring of heart rate, blood pressure, cardiac rhythm, and tissue perfusion is essential during administration.

Administration Details

• The epinephrine infusion can be prepared by adding 1 mg (1 mL) of a 1:1000 dilution of epinephrine to 250 mL of D5W to yield a concentration of 4.0 mg/mL, as described in the 2005 practice parameter for the diagnosis and management of anaphylaxis 1.
• The solution is infused intravenously at a rate of 1 to 4 mg/min (15 to 60 drops per minute with a microdrop apparatus), increasing to a maximum of 10.0 mg/min for adults and adolescents.

Special Considerations

• Because of the risk for potentially lethal arrhythmias, epinephrine should be administered intravenously only during cardiac arrest or to profoundly hypotensive subjects who have failed to respond to intravenous volume replacement and several injected doses of epinephrine.
• In situations where hemodynamic monitoring is available, continuous hemodynamic monitoring is essential.
• If intravenous epinephrine is considered essential under special circumstances, monitoring by available means (e.g., every-minute blood pressure and pulse measurements and electrocardiographic monitoring, if available) should be conducted.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Hypotension associated with septic shock: ... Intravenous infusion rate of 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired mean arterial pressure. To provide hemodynamic support in septic shock associated hypotension in adult patients, the suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP).

The recommended epinephrine infusion dosage is between 0.05 mcg/kg/min and 2 mcg/kg/min, titrated to achieve the desired mean arterial pressure. The dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min. Weaning should be done incrementally over time, such as by decreasing doses of epinephrine every 30 minutes over a 12- to 24-hour period 2 2.

From the Research

Epinephrine Infusion Dosage

• The ideal dosage for epinephrine infusion is not explicitly stated in the provided studies, but it is mentioned that intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation 3, 4.
• A study comparing routes of epinephrine administration found that intravenous bolus epinephrine was associated with a higher risk of cardiovascular complications and overdose compared to intramuscular epinephrine 5.
• The American Heart Association recommends epinephrine as part of Advanced Cardiac Life Support for cardiac arrest, but the literature behind its use is not strong, and high-dose epinephrine is harmful and not recommended 6.
• The provided studies do not specify a particular dosage for epinephrine infusion, but they emphasize the importance of caution and proper administration to avoid adverse effects 3, 4, 5, 6.

Administration Routes

• Intramuscular epinephrine is the immediate treatment of choice for anaphylaxis 3, 4.
• Intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation 3, 4.
• Subcutaneous injection or inhalation from a pressurized metered-dose inhaler are not recommended as they are sub-optimal routes of administration 7.

Special Considerations

• Delay in treatment, administration of epinephrine by sub-optimal routes, administration of an inappropriately low epinephrine dose, and injection of 'outdated' epinephrine can lead to inadequate treatment of anaphylaxis 7.
• Additional fixed-dose formulations of epinephrine are needed to facilitate optimal first-aid dosing in patients of all ages and sizes 7.