What is the recommended dose of epinephrine (adrenaline) for pediatric cardiac arrest?

Epinephrine Dosing for Pediatric Cardiac Arrest

The recommended dose of epinephrine for pediatric cardiac arrest is 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) administered IV or IO every 3-5 minutes, with a maximum single dose of 1 mg. 1

Standard Dosing Protocol

• Administer 0.01 mg/kg IV/IO (using 1:10,000 concentration = 0.1 mg/mL) as the initial dose and for all subsequent doses 1
• The maximum single dose is 1 mg regardless of weight 1
• Repeat every 3-5 minutes during ongoing cardiac arrest 1, 2
• Use IV or IO routes as preferred vascular access; both are equally acceptable and effective 1

Route-Specific Considerations

Intravenous/Intraosseous (Preferred):

• IV and IO are the preferred routes with equivalent efficacy 1
• IO access should be considered early when IV access is not readily attainable 1
• Standard dose of 0.01 mg/kg applies to both routes 1

Endotracheal (Only if IV/IO unavailable):

• If epinephrine must be given via endotracheal tube, use 0.1 mg/kg (10 times the IV dose) 1
• This higher dose is necessary because tracheal administration requires up to 10 times the IV dose to achieve equivalent biological effect 1
• Tracheal doses <0.1 mg/kg produce transient deleterious β-adrenergic vascular effects resulting in lower coronary artery perfusion 1

Critical Evidence Against High-Dose Epinephrine

High-dose epinephrine (0.1 mg/kg IV/IO) as rescue therapy is associated with worse outcomes and should NOT be used. 3, 4

• A prospective randomized controlled trial demonstrated that high-dose epinephrine (0.1 mg/kg) resulted in lower 24-hour survival compared to standard-dose (0.01 mg/kg): only 1 of 34 patients (3%) survived 24 hours with high-dose versus 7 of 34 (21%) with standard-dose (odds ratio for death 8.6, P=0.05) 3
• Zero patients in the high-dose group survived to hospital discharge, compared to 4 patients in the standard-dose group 3
• Among patients with asphyxial arrest specifically, none of the 12 patients receiving high-dose epinephrine survived 24 hours, compared to 7 of 18 receiving standard-dose (P=0.02) 3
• The 2010 International Consensus concluded that doses >10 mcg/kg (0.01 mg/kg) showed no improvement in survival to hospital discharge or neurologic outcome 1

Timing Considerations

Administer the initial dose as early as possible in the resuscitation for nonshockable rhythms. 1

• For nonshockable in-hospital and out-of-hospital cardiac arrest, give epinephrine as early in the resuscitation as possible (weak recommendation, very low-certainty evidence) 1
• For shockable rhythms, no specific recommendation can be made regarding timing of initial epinephrine dose 1
• Repeat doses every 3-5 minutes throughout the arrest 1, 2

Regarding dosing intervals: While one recent study suggested that epinephrine dosing intervals ≤2 minutes were associated with improved outcomes compared to >2 minutes 5, the established guideline recommendation remains every 3-5 minutes 1. The 2020 International Consensus stated they cannot make a recommendation about optimal interval for subsequent doses due to very low confidence in effect estimates 1.

Common Pitfalls to Avoid

• Never use high-dose epinephrine (0.1 mg/kg) IV/IO - this is associated with decreased survival and potential harm 3, 4
• Do not confuse IV/IO dosing (0.01 mg/kg) with endotracheal dosing (0.1 mg/kg) - the routes require different doses 1
• Do not use tracheal doses <0.1 mg/kg - lower tracheal doses (0.01-0.05 mg/kg) produce deleterious β-adrenergic effects 1
• Do not delay epinephrine administration - early administration is associated with better outcomes in nonshockable rhythms 1
• Do not exceed 1 mg maximum single dose even in larger children or adolescents 1

Preparation and Administration

• Use 1:10,000 concentration (0.1 mg/mL) for IV/IO administration 6
• Calculate dose: 0.01 mg/kg = 0.1 mL/kg of 1:10,000 solution 1
• For a 10 kg child: 0.1 mg = 1 mL of 1:10,000 solution
• For a 20 kg child: 0.2 mg = 2 mL of 1:10,000 solution
• Follow each IO dose with a saline flush to promote entry into central circulation 7