What is the recommended rate of adrenaline (epinephrine) infusion?

Adrenaline (Epinephrine) Infusion Rate

For septic shock-associated hypotension in adults, start epinephrine at 0.05-0.1 mcg/kg/min (approximately 3.5-7 mcg/min for a 70 kg patient) and titrate every 10-15 minutes by increments of 0.05-0.2 mcg/kg/min to achieve a target mean arterial pressure of 65 mmHg, with a maximum rate of 2 mcg/kg/min. 1

Standard Preparation and Concentration

• Dilute 1 mg (1 mL) of 1:1000 epinephrine in 250 mL of D5W to yield a concentration of 4 mcg/mL (1:250,000 solution). 2
• Infuse at 1-4 mcg/min initially (15-60 drops per minute with microdrop apparatus), increasing to a maximum of 10 mcg/min for adults and adolescents. 2
• For septic shock specifically, the FDA-approved preparation uses 1 mg in 1,000 mL of 5% dextrose to produce a 1 mcg/mL dilution. 1

Clinical Context: Anaphylaxis vs. Septic Shock

For Anaphylaxis (Refractory Cases Only)

• Intramuscular injection is the first-line route for anaphylaxis, NOT intravenous infusion. 3
• If multiple IM doses fail and IV infusion becomes necessary, use the alternative concentration: 1 mg epinephrine in 100 mL saline (1:100,000 solution) at an initial rate of 30-100 mL/h (5-15 mcg/min), titrated based on clinical response. 2
• This infusion should be discontinued 30 minutes after resolution of all anaphylaxis signs and symptoms. 2

For Septic Shock

• Start at 0.05 mcg/kg/min and titrate to achieve desired MAP, adjusting every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min. 1
• After hemodynamic stabilization, wean incrementally over 12-24 hours by decreasing doses every 30 minutes. 1

Pediatric Dosing

• For children, use 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) up to 10 mcg/min, with a maximum single dose of 0.3 mg. 2
• Alternative "Rule of 6" method: 0.6 × body weight (kg) = milligrams diluted to 100 mL saline; then 1 mL/h delivers 0.1 mcg/kg/min. 2
• Typical pediatric range is 0.1-1.0 mcg/kg/min, starting at the lowest dose and titrating to effect. 4

Administration Route and Monitoring

• Administer through a large central vein whenever possible to avoid tissue necrosis from extravasation. 1
• Avoid catheter tie-in techniques and leg veins in elderly or those with occlusive vascular disease. 1
• If extravasation occurs, infiltrate 5-10 mg phentolamine diluted in 10-15 mL saline at the site immediately. 4
• Monitor blood pressure and heart rate every 5-15 minutes during initial titration. 4

Critical Pitfalls to Avoid

• Do NOT use saline solution alone for dilution—always use 5% dextrose or dextrose with sodium chloride. 1
• Do NOT mix epinephrine with sodium bicarbonate or other alkaline solutions, as adrenergic agents are inactivated in alkaline environments. 4
• Do NOT confuse concentrations: 1:1000 (1 mg/mL) is for IM injection; 1:10,000 is for IV bolus; 1:250,000 or 1:100,000 are for continuous infusion. 2, 3
• Ensure adequate volume resuscitation before or concurrent with epinephrine infusion to optimize cardiac output and prevent severe organ hypoperfusion. 4

Important Nuances

The evidence distinguishes clearly between anaphylaxis management (where IM remains preferred) and septic shock (where IV infusion is standard). 3, 1 While older guidelines from 2005 suggest no established dosage regimen for IV epinephrine in anaphylaxis 2, the FDA label provides specific guidance for septic shock that should be followed in that context. 1 The alternative 1:100,000 concentration for anaphylaxis comes from a prospective randomized study showing 18 of 19 patients achieved symptomatic improvement within 5 minutes. 2