How to administer an adrenaline (epinephrine) drip in an emergency?

How to Administer an Adrenaline Drip in an Emergency

For shock refractory to volume resuscitation, start an adrenaline infusion at 0.1 mcg/kg/min and titrate upward to 1.0 mcg/kg/min based on blood pressure response, with doses occasionally reaching 5 mcg/kg/min in severe cases. 1, 2

Preparation of the Infusion

• Mix 1 mg of adrenaline (1 mL of 1:1000 solution) in 100 mL of normal saline to create a 1:100,000 concentration (10 mcg/mL). 2
• For pediatric patients, prepare the infusion by adding adrenaline to achieve a concentration that allows precise dosing based on weight. 1
• Use an infusion pump for accurate delivery—manual drip calculations are error-prone in emergency situations. 2

Dosing by Clinical Indication

For Refractory Shock (Post-Resuscitation or Septic Shock)

• Start at 0.1 mcg/kg/min and titrate upward to achieve adequate blood pressure, typically targeting mean arterial pressure >65 mmHg. 1, 2
• The usual effective range is 0.1–1.0 mcg/kg/min, though doses up to 5 mcg/kg/min may be necessary in severe distributive shock. 1
• For adults, this translates to starting at approximately 1–4 mcg/min (15–60 drops/min with microdrop apparatus) and increasing to a maximum of 10 mcg/min. 2

For Severe Anaphylaxis Unresponsive to IM Epinephrine

• After adequate fluid resuscitation (20 mL/kg boluses), initiate continuous infusion at 1–4 mcg/min for adults, titrating to blood pressure response. 2, 3
• For children, use 0.05–0.1 mcg/kg/min as the starting infusion rate. 3
• This indication applies only when multiple IM doses (0.3–0.5 mg every 5–15 minutes) have failed to stabilize the patient. 2, 3

For Cardiac Arrest (During Active CPR)

• Do not use continuous infusion during cardiac arrest—give 1 mg IV/IO boluses every 3–5 minutes instead. 1
• The pediatric dose is 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO, maximum 1 mg per dose, repeated every 3–5 minutes. 1
• High-dose epinephrine regimens have not improved survival or neurological outcomes and are not recommended. 1

Route of Administration

• Establish IV access—preferably central venous, but peripheral IV or intraosseous (IO) access is acceptable if central access is unavailable. 2
• Central venous administration delivers drugs more rapidly to the central circulation but should not delay resuscitation efforts. 1
• IV access is superior to IO for adrenaline during cardiac arrest, with better odds of return of spontaneous circulation (OR 1.37) and survival (OR 1.47). 4
• Never administer continuous adrenaline infusions via endotracheal tube—this route is only for bolus dosing during cardiac arrest when vascular access is unavailable. 1

Monitoring Requirements

• Measure blood pressure every 5–15 minutes during infusion. 2
• Continuous cardiac monitoring is mandatory—adrenaline can cause tachyarrhythmias, ventricular ectopy, and potentially lethal arrhythmias. 1, 2
• Frequently inspect the IV site for extravasation, as infiltration causes severe tissue necrosis. 1, 2
• If extravasation occurs, inject phentolamine 0.1–0.2 mg/kg (maximum 10 mg) diluted in 10 mL of normal saline intradermally at the site to counteract vasoconstriction. 1

Critical Pitfalls to Avoid

• Do not confuse 1:1000 (1 mg/mL) and 1:10,000 (0.1 mg/mL) concentrations—verify the concentration before drawing up doses. 1
• For IV bolus dosing during cardiac arrest, use 1:10,000 concentration; for IM injection in anaphylaxis, use 1:1000 concentration. 1
• Exercise extreme caution when giving adrenaline to patients on beta-blockers, or those with cocaine/sympathomimetic drug intoxication—consider glucagon 1–5 mg IV over 5 minutes for beta-blocker patients with refractory hypotension. 1, 2
• Adrenaline has a short half-life requiring continuous infusion rather than intermittent boluses for sustained vasopressor effect in shock states. 2
• Flush peripheral IV lines with 20 mL of normal saline after each bolus dose to ensure drug delivery to central circulation. 1

Special Considerations for Pediatrics

• For children requiring IV adrenaline in acute settings, prepare 1 mL of 1:10,000 adrenaline for each 10 kg body weight in a syringe, starting with one-tenth of the syringe contents (1 mcg/kg) and titrating to response. 2
• Use length-based resuscitation tapes with precalculated doses when weight is unknown—these are more accurate than age-based estimates. 1
• The infusion dosing range for pediatric shock is identical to adults: 0.1–1.0 mcg/kg/min, titrated to effect. 1