How do I add an epinephrine (epi) drip to a patient on levophed (norepinephrine) at 30mcg/min in the setting of profound and acute hypotension?

Adding Epinephrine to High-Dose Norepinephrine in Profound Hypotension

Start an epinephrine infusion at 0.1-0.5 mcg/kg/min (7-35 mcg/min in a 70 kg adult) when norepinephrine reaches 0.25 mcg/kg/min (approximately 17.5 mcg/min or 1.05 mg/h in a 70 kg patient) and hypotension persists, while ensuring adequate fluid resuscitation with at least 30 mL/kg crystalloid bolus has been administered. 1

Critical Pre-Requirements Before Adding Epinephrine

• Verify adequate volume resuscitation first - you must have given at least 30 mL/kg crystalloid bolus before or concurrent with vasopressor escalation, as vasoconstriction in hypovolemic patients causes severe organ hypoperfusion despite "normal" blood pressure 1, 2

• Confirm central venous access - both norepinephrine and epinephrine should be administered through central venous access to minimize extravasation risk and tissue necrosis 1, 3

• Place arterial line immediately if not already present for continuous blood pressure monitoring during dual vasopressor therapy 1

Epinephrine Preparation and Initial Dosing

• Standard concentration: Add 4 mg epinephrine to 250 mL D5W to yield 16 mcg/mL (same concentration preparation as norepinephrine) 1

• Starting dose: Begin at 0.1 mcg/kg/min (7 mcg/min in a 70 kg adult, which equals approximately 26 mL/h with standard 16 mcg/mL concentration) 1

• Alternative for anaphylaxis context: If the profound hypotension is anaphylaxis-related, prepare 1 mg epinephrine in 100 mL saline (1:100,000 solution) and start at 30-100 mL/h (5-15 mcg/min) 2

Titration Protocol for Epinephrine

• Monitor blood pressure and heart rate every 5-15 minutes during initial titration 1

• Target MAP of 65 mmHg as your primary endpoint, while also assessing tissue perfusion markers: lactate clearance, urine output >50 mL/h, mental status, and capillary refill 1, 3

• Titrate upward by doubling the dose every 15 minutes if inadequate response, up to maximum 0.5 mcg/kg/min (35 mcg/min in 70 kg adult) 1, 2

• Do NOT increase epinephrine beyond 0.5 mcg/kg/min - instead add additional agents (see below) 1

Simultaneous Management of Norepinephrine

• Continue norepinephrine at current dose (30 mcg/min) when initiating epinephrine - do not decrease it 1

• Consider adding vasopressin 0.03-0.04 units/min as third-line agent if MAP remains <65 mmHg despite norepinephrine 0.25 mcg/kg/min plus epinephrine 1

• Do NOT increase vasopressin above 0.04 units/min - reserve higher doses only for salvage therapy 1

Critical Monitoring Parameters

• Assess for excessive vasoconstriction: cold extremities, decreased urine output, rising lactate despite adequate MAP 1

• Watch for tachyarrhythmias - epinephrine has more beta-1 activity than norepinephrine and increases risk of arrhythmias, particularly at higher doses 3, 2

• Monitor for increased myocardial oxygen demand - epinephrine significantly increases heart rate and contractility, which may precipitate ischemia in susceptible patients 3

• Do NOT mix epinephrine with sodium bicarbonate or alkaline solutions in the IV line, as epinephrine is inactivated in alkaline solutions 2

When to Add Inotropic Support Instead

• If evidence of myocardial dysfunction exists (low cardiac output on echo, elevated troponin, known cardiomyopathy), consider adding dobutamine 2.5-20 mcg/kg/min rather than escalating epinephrine further 1

• Start dobutamine at 2.5 mcg/kg/min and double every 15 minutes based on response, with dose titration usually limited by excessive tachycardia, arrhythmias, or ischemia 1

Common Pitfalls to Avoid

• Never add epinephrine without ensuring adequate fluid resuscitation - this is the most critical error, as vasopressors in hypovolemic patients worsen organ perfusion 1, 4

• Do not use dopamine as an alternative - it is associated with higher mortality and more arrhythmias compared to norepinephrine/epinephrine 1

• Avoid phenylephrine as first-line alternative - it may raise blood pressure while worsening tissue perfusion due to pure alpha-agonism without beta effects 1

• Do not delay epinephrine addition if norepinephrine is already at 30 mcg/min (>0.25 mcg/kg/min in most adults) - you are already past the threshold for adding second-line agents 1

Special Consideration for Your Specific Scenario

At 30 mcg/min norepinephrine (approximately 0.43 mcg/kg/min in a 70 kg patient), you are already well above the 0.25 mcg/kg/min threshold where guidelines recommend adding epinephrine 1. The profound and acute nature of your patient's hypotension suggests either:

1. Inadequate volume resuscitation - verify 30 mL/kg crystalloid given 1
2. Distributive shock component - epinephrine addition is appropriate 1
3. Cardiogenic component - consider dobutamine instead if myocardial dysfunction present 1

Start the epinephrine infusion immediately at 0.1 mcg/kg/min while simultaneously reassessing volume status and considering vasopressin as third-line agent. 1