What is the dose and preparation of epinephrine (adrenaline) infusion for a pediatric patient?

Epinephrine Infusion Dosing and Preparation for Pediatric Patients

For pediatric patients requiring continuous epinephrine infusion (typically for refractory anaphylaxis or shock), start at 0.1 mcg/kg/min and titrate up to 1.0 mcg/kg/min based on clinical response, with doses up to 5 mcg/kg/min sometimes necessary in severe cases. 1

Standard Preparation Methods

Rule of 6 Method (Simplified Pediatric Dosing)

• Multiply 0.6 × patient's weight in kg = number of milligrams of epinephrine
• Add this amount to normal saline to make a total volume of 100 mL
• At this concentration, 1 mL/hour delivers 0.1 mcg/kg/min 1
• This method eliminates complex calculations at the bedside and reduces dosing errors

Alternative Standard Concentration

• Add 1 mg (1 mL) of 1:1000 epinephrine to 250 mL of D5W
• This yields a concentration of 4.0 mcg/mL 2, 3
• Start infusion at 15-60 drops/min using a microdrop apparatus 3
• Titrate to achieve hemodynamic stability

Dosing Algorithm

Initial Dosing

• Start at 0.1 mcg/kg/min for most pediatric patients 1
• This is the safest starting point that allows for upward titration based on response

Titration Strategy

• Typical therapeutic range: 0.1-1.0 mcg/kg/min 1
• Monitor blood pressure, heart rate, and perfusion markers every 5-15 minutes during titration 1
• Increase dose incrementally if inadequate response (persistent hypotension, poor perfusion)
• Maximum doses up to 5 mcg/kg/min may be required in refractory cases 1

When to Use Continuous Infusion

Epinephrine infusion should only be initiated after:

• Multiple intramuscular doses (typically 2-3 doses at 5-minute intervals) have failed to achieve adequate response 2, 3
• Patient has received aggressive volume resuscitation (minimum 30 mL/kg crystalloid) 1
• Continuous hemodynamic monitoring is available 2, 3

Administration Route and Monitoring

Access Requirements

• Central venous access is strongly preferred to minimize extravasation risk and tissue necrosis 1
• If central access unavailable, peripheral IV or intraosseous can be used temporarily during initial resuscitation 1
• Transition to central line as soon as practical for prolonged infusion

Critical Monitoring Parameters

• Blood pressure and heart rate every 5-15 minutes initially 1
• Capillary refill time and mental status 1
• Urine output (target >50 mL/hour for 4 hours) 1
• Signs of excessive vasoconstriction (cold extremities, decreased perfusion) 1

Solution Inspection Before Use

Always visually inspect epinephrine solution before preparation: 2

• Solution should be clear and colorless
• Discard if yellow, brown, or pink (indicates oxidation/degradation)
• Discard if cloudy or contains particulate matter (indicates contamination)
• Discard if crystals are present

Common Pitfalls to Avoid

Concentration Confusion

• Never confuse 1:1000 (1 mg/mL) with 1:10,000 (0.1 mg/mL) 3
• For continuous infusion, use 1:1000 concentration diluted as described above
• 1:10,000 is reserved for IV bolus dosing in cardiac arrest, not continuous infusion

Inadequate Volume Resuscitation

• Do not start epinephrine infusion without adequate fluid resuscitation 1
• Vasoconstriction in a hypovolemic patient causes severe organ hypoperfusion despite "normal" blood pressure
• Ensure at least 30 mL/kg crystalloid bolus given before or concurrent with infusion

Premature Escalation to Infusion

• Intramuscular epinephrine (0.01 mg/kg, max 0.5 mg) remains first-line treatment 4, 2
• Can repeat IM doses every 5 minutes as needed 2, 3
• 10-20% of patients require 2-3 IM doses before response 4, 2
• There is no maximum number of IM doses—continue until response or transition to infusion 3

Extravasation Management

• If extravasation occurs, immediately infiltrate phentolamine 0.1-0.2 mg/kg (up to 10 mg) diluted in 10 mL of 0.9% sodium chloride intradermally at the site 1
• This prevents tissue necrosis from dermal vasoconstriction

Special Considerations for Anaphylaxis

• Epinephrine infusion for anaphylaxis should start at 1-4 mcg/min (not mcg/kg/min) and titrate up to maximum 10 mcg/min 2, 3
• This applies when transitioning from failed IM dosing in anaphylaxis specifically
• Concurrent aggressive volume replacement with 1000-2000 mL normal saline in adults (20 mL/kg in children) is mandatory 2
• There is no absolute contraindication to epinephrine in anaphylaxis, even in patients with cardiac disease 2