What is the recommended dose and administration protocol for an epinephrine (adrenaline) intravenous (IV) push?

Epinephrine IV Push Dosing and Administration

For cardiac arrest, administer 1 mg (10 mL of 1:10,000 or 0.1 mg/mL solution) IV push every 3-5 minutes; for anaphylactic shock with IV access, use 0.05-0.1 mg (50-100 mcg) IV push, which is 5-10% of the cardiac arrest dose. 1

Cardiac Arrest Dosing

• Standard dose: 1 mg IV/IO every 3-5 minutes during active resuscitation until return of spontaneous circulation (ROSC) or termination of efforts 1
• Prepare as 1 mg in 10 mL (1:10,000 concentration = 0.1 mg/mL) for IV push administration 1
• Flush with at least 5 mL normal saline after each dose to ensure drug delivery into central circulation 1
• If IV/IO access unavailable, endotracheal dose is 0.1 mg/kg (10 times the IV dose, using 1:1000 concentration), though this route is less effective and associated with worse outcomes 1

Anaphylactic Shock Dosing (Non-Arrest)

• IV bolus: 0.05-0.1 mg (50-100 mcg) every 2-5 minutes as needed for persistent hypotension or bronchospasm despite intramuscular epinephrine 1
• Prepare "dirty epinephrine" at bedside: draw 1 mL of 1:1000 epinephrine (1 mg) and add 9 mL normal saline to create 10 mL of 1:10,000 solution (100 mcg/mL) 2
• For Grade II anaphylaxis (moderate hypotension/bronchospasm): start with 20 mcg (0.2 mL), escalate to 50 mcg if unresponsive at 2 minutes 2
• For Grade III anaphylaxis (life-threatening): start with 50-100 mcg (0.5-1.0 mL), escalate to 200 mcg if unresponsive at 2 minutes 2
• Critical: Administer aggressive crystalloid boluses (500-1000 mL rapid bolus) concurrently with epinephrine, as vasoconstriction without volume causes organ hypoperfusion 2

Continuous Infusion for Refractory Anaphylaxis

• If multiple IV boluses fail to resolve shock, transition to continuous infusion: 1-4 mcg/min initially, titrate up to maximum 10 mcg/min 3
• Prepare by diluting 1 mg epinephrine in 250 mL D5W to create 4 mcg/mL concentration 3
• Requires continuous hemodynamic monitoring and aggressive volume replacement (1000-2000 mL normal saline in adults) 3

Septic Shock Dosing (Continuous Infusion)

• Start at 0.05 mcg/kg/min, titrate to 2 mcg/kg/min to achieve target MAP ≥65 mmHg 4
• Dilute 1 mg (10 mL) in 1000 mL of 5% dextrose to produce 1 mcg/mL solution 4
• Adjust every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min based on blood pressure response 4
• After stabilization, wean incrementally over 12-24 hours 4

Push Dose Epinephrine for Transient Hypotension

• 10-20 mcg IV push every 2 minutes until SBP ≥90 mmHg or MAP ≥65 mmHg 5
• Effective for temporary correction of hypotension during critical care transport, with median MAP increase of 13 mmHg 5
• Adverse events are rare when dosed appropriately; one study of 100 doses showed single episode of transient extreme hypertension without patient harm 5

Administration Route and Monitoring

• Administer into a large vein whenever possible; avoid leg veins in elderly or those with vascular disease 4
• Central venous access strongly preferred for continuous infusions to minimize extravasation risk 1
• If extravasation occurs, immediately infiltrate 5-10 mg phentolamine diluted in 10-15 mL saline at the site to prevent tissue necrosis 1
• Inspect solution before use: discard if discolored (yellow, brown, pink), cloudy, or contains particulate matter 3, 4

Critical Pitfalls to Avoid

• Do not confuse 1:1000 (1 mg/mL) with 1:10,000 (0.1 mg/mL) concentrations—using 1:1000 IV when 1:10,000 is indicated delivers 10 times the intended dose 2
• Never administer epinephrine in saline solution alone for continuous infusions; use 5% dextrose or dextrose-saline combinations 4
• Do not mix with sodium bicarbonate or alkaline solutions in the IV line, as epinephrine is inactivated in alkaline environments 1
• For anaphylaxis, intramuscular remains the preferred initial route (0.3-0.5 mg in anterolateral thigh); IV route is reserved for refractory cases with established IV access 1, 3
• Address hypovolemia first with crystalloid boluses before or concurrent with epinephrine administration to prevent severe organ hypoperfusion from vasoconstriction in hypovolemic state 2

Pediatric Considerations

• Cardiac arrest: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000), maximum 1 mg per dose 1
• Endotracheal: 0.1 mg/kg (0.1 mL/kg of 1:1000), maximum 2.5 mg 1
• For neonatal resuscitation: prepare 0.02 mg/kg (0.2 mL/kg of 1:10,000) in 1 mL syringe for IV administration 6