How to titrate an epinephrine (epi) drip?

Epinephrine Drip Titration

For septic shock-associated hypotension, start epinephrine at 0.05 mcg/kg/min and titrate every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min to achieve a target mean arterial pressure (MAP) of 65 mmHg, with a maximum dose of 2 mcg/kg/min. 1

Preparation and Concentration

• Dilute 1 mg (10 mL) of epinephrine in 1,000 mL of 5% dextrose solution or 5% dextrose with sodium chloride to produce a 1 mcg/mL concentration. 1
• Avoid using saline solution alone for dilution. 1
• The diluted solution can be stored for up to 4 hours at room temperature or 24 hours under refrigeration. 1

Administration Route

• Infuse epinephrine into a large vein whenever possible, preferably through central venous access. 1
• Avoid using leg veins in elderly patients or those with occlusive vascular disease. 1
• Avoid catheter tie-in techniques, as obstruction to blood flow around the tubing may cause stasis and increased local drug concentration. 1

Initial Dosing and Titration Protocol

• Start at 0.05 mcg/kg/min and titrate to achieve desired MAP. 1
• Adjust the dose every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min based on blood pressure response. 1
• The dosing range extends from 0.05 mcg/kg/min up to a maximum of 2 mcg/kg/min. 1

Target Blood Pressure

• Target a MAP of 65 mmHg for most patients with septic shock. 2
• Patients with chronic hypertension or atherosclerosis may require higher MAP targets, while younger normotensive patients may tolerate lower pressures. 2

Monitoring Requirements

• Monitor blood pressure and heart rate every 5-15 minutes during initial titration. 2
• Assess tissue perfusion markers including lactate clearance, urine output (target >50 mL/h), mental status, and capillary refill. 2
• Place an arterial catheter as soon as practical for continuous blood pressure monitoring. 2

Weaning Strategy

• After hemodynamic stabilization, wean incrementally over time by decreasing doses every 30 minutes over a 12-24 hour period. 1

Special Considerations for Anaphylaxis

For anaphylaxis not responding to intramuscular epinephrine and volume resuscitation:

• Add 1 mg (1 mL of 1:1000) epinephrine to 1,000 mL of 0.9% normal saline. 3
• Start the infusion at 2 mcg/min (2 mL/min, equivalent to 120 mL/h). 3
• Increase up to 10 mcg/min (10 mL/min, equivalent to 600 mL/h), titrating continuously according to blood pressure, heart rate, and oxygenation. 3
• An alternative 1:100,000 solution (1 mg in 100 mL saline) can be administered at 30-100 mL/h (5-15 mcg/min), titrated based on clinical response. 2

Critical Pitfalls to Avoid

• Never start epinephrine without ensuring adequate volume resuscitation. Address hypovolemia with crystalloid boluses (minimum 30 mL/kg) before or concurrent with epinephrine initiation, as vasoconstriction in hypovolemic patients causes severe organ hypoperfusion despite "normal" blood pressure. 2
• Watch for extravasation into tissues, which can cause local necrosis. If extravasation occurs, infiltrate 5-10 mg of phentolamine diluted in 10-15 mL of saline at the site as soon as possible. 1
• Monitor for potentially serious cardiac arrhythmias and myocardial ischemia, particularly in patients with underlying heart disease. 1
• Be alert for acute severe hypertension and pulmonary edema, which may be fatal. 1
• Do not mix epinephrine with sodium bicarbonate or other alkaline solutions in the IV line, as adrenergic agents are inactivated in alkaline solutions. 2

Evidence Considerations

The FDA-approved dosing for septic shock provides the most authoritative guidance, with a clear titration protocol every 10-15 minutes. 1 This differs from the anaphylaxis guidelines, which use fixed infusion rates rather than weight-based dosing. 3 Animal studies suggest that continuous infusion produces superior hemodynamic recovery compared to bolus dosing in anaphylactic shock, supporting the infusion approach. 4 The physiologic threshold for epinephrine's hemodynamic effects begins at plasma concentrations of 50-100 pg/ml, well within the range achieved by these dosing protocols. 5