What is the rescue dose adjustment for an epinephrine (adrenaline) drip?

Rescue Dose for Epinephrine Drip

For refractory hypotension during cardiac arrest or anaphylaxis not responding to initial epinephrine boluses, increase the continuous epinephrine infusion to 4-10 mg/min (or 0.1-0.2 mcg/kg/min in children), with rapid escalation from 1-3 mg over 3 minutes to 3-5 mg over 3 minutes, then to the 4-10 mg/min infusion rate. 1

Cardiac Arrest Context

Adult Dosing Escalation

• Initial resuscitation sequence: Administer 1-3 mg (1:10,000 dilution) slowly IV over 3 minutes, followed by 3-5 mg IV over 3 minutes, then escalate to a 4-10 mg/min continuous infusion for ongoing cardiac arrest 1
• This represents a rapid progression to high-dose epinephrine when standard doses fail to achieve return of spontaneous circulation 1

Pediatric Dosing Escalation

• Initial dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution, maximum 1 mg) repeated every 3-5 minutes 1
• Rescue escalation: For unresponsive asystole or pulseless electrical activity, increase to 0.1-0.2 mg/kg (0.1 mL/kg of 1:1,000 solution) 1
• Standard dosing should be repeated every 3-5 minutes during ongoing arrest 1

Important caveat: High-dose epinephrine may be harmful, particularly in asphyxial arrest, and should be reserved for exceptional circumstances such as beta-blocker overdose 1

Hemodynamic Support Context (Non-Arrest)

Standard Infusion Dosing

• Starting rate: 0.05-2 mcg/kg/min for septic shock-associated hypotension 2
• Titration: Adjust every 10-15 minutes in increments of 0.05-0.2 mcg/kg/min to achieve desired mean arterial pressure 2
• Preparation: Dilute 1 mg in 1,000 mL of 5% dextrose to produce 1 mcg/mL concentration 2

When Standard Dosing Fails

The concept of "rescue dose" in continuous infusion differs from cardiac arrest—instead of a single bolus escalation, you progressively titrate upward within the therapeutic range until hemodynamic goals are met or maximum safe doses are reached 2

Anaphylaxis-Specific Considerations

Refractory Hypotension Management

• After failed IM epinephrine: If hypotension persists despite adequate IM epinephrine injections (0.3-0.5 mg every 5-15 minutes) and volume replacement, initiate continuous infusion 1
• Infusion preparation: Add 1 mg epinephrine to 100 mL saline (1:100,000 solution), infuse at 30-100 mL/h (5-15 mcg/min), titrated to clinical response 3
• Bronchospasm resistant to epinephrine should prompt addition of inhaled beta-agonists (albuterol 2.5-5 mg nebulized) rather than increasing epinephrine dose 1

Critical Monitoring During Dose Escalation

• Hemodynamic parameters: Monitor blood pressure every 5-15 minutes during titration 3
• Perfusion markers: Assess capillary refill, urine output (target >50 mL/h), mental status, and lactate clearance 3
• Cardiac effects: Watch for excessive tachycardia, arrhythmias, or myocardial ischemia that may limit dose escalation 3

Common Pitfalls to Avoid

• Inadequate volume resuscitation: Never escalate epinephrine without ensuring adequate fluid resuscitation (minimum 30 mL/kg crystalloid), as vasoconstriction in hypovolemic patients causes severe organ hypoperfusion despite "normal" blood pressure 3
• Prolonged low-dose therapy: In cardiac arrest, rapid escalation to high-dose is more appropriate than prolonged administration of standard doses when initial therapy fails 1
• Ignoring alternative vasopressors: Consider adding vasopressin (0.03-0.04 units/min in adults, 0.0002-0.002 units/kg/min in children) when epinephrine reaches 0.25 mcg/kg/min and hypotension persists, rather than continuing to escalate epinephrine alone 3
• Extravasation risk: Administer through central venous access when possible; if extravasation occurs, immediately infiltrate phentolamine 5-10 mg diluted in 10-15 mL saline at the site 3