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

Epinephrine Dosing for Pediatric Cardiac Arrest

For pediatric cardiac arrest, administer epinephrine 0.01 mg/kg (10 mcg/kg) IV/IO every 3-5 minutes, with a maximum single dose of 1 mg. 1

Standard Dosing Protocol

The preferred routes are intravenous (IV) or intraosseous (IO), not endotracheal. 2 The standard concentration for IV/IO administration is 1:10,000 (0.1 mg/mL). 3

• Dose: 0.01 mg/kg (10 mcg/kg) IV/IO 1
• Maximum single dose: 1 mg 1
• Frequency: Every 3-5 minutes during ongoing cardiac arrest 1, 3
• Continue: Repeat doses every 3-5 minutes as long as cardiac arrest persists 3

Critical Dosing Considerations

High-dose epinephrine (0.1 mg/kg) should NOT be used in pediatric cardiac arrest. 1 Despite one older case series suggesting benefit from high-dose epinephrine (0.1 mg/kg) after failure of two standard doses 2, subsequent evidence demonstrates that high-dose epinephrine is associated with reduced 24-hour survival and does not improve neurologic outcomes. 1 A planned secondary analysis of a pediatric randomized controlled trial showed increased risk of mortality with high-dose IV epinephrine (0.1 mg/kg). 2

Administer the initial dose as early in the resuscitation as possible. 2 The 2020 International Consensus strongly suggests early administration of the initial epinephrine dose in pediatric patients with nonshockable cardiac arrest. 2

Route-Specific Dosing

IV/IO Administration (Preferred)

• Standard dose: 0.01 mg/kg IV/IO 1
• Concentration: 1:10,000 (0.1 mg/mL) 3
• Interval: Every 3-5 minutes 1

Endotracheal Administration (Only if IV/IO Unavailable)

If vascular access cannot be established, endotracheal epinephrine may be used, but requires a higher dose of 0.1 mg/kg to achieve equivalent biological effect. 2 However, endotracheal administration results in lower and more unpredictable drug levels compared to IV/IO routes. 2

Special Population: Neonates

For neonates with heart rate <60 bpm despite adequate ventilation and chest compressions:

• IV dose: 0.01 to 0.03 mg/kg 2
• Endotracheal dose: 0.05 to 0.1 mg/kg (if IV access not available) 2
• Higher IV doses (>0.03 mg/kg) cannot be recommended and may be harmful 2

Dosing Interval Considerations

While the standard recommendation remains every 3-5 minutes 1, emerging evidence suggests nuanced timing considerations:

• Very frequent dosing (<3 minutes) may be associated with harm compared to 3-5 minute intervals 2
• One single-center study found that dosing intervals ≤2 minutes were associated with improved outcomes, largely by shortening CPR duration 4
• However, the 2020 International Consensus states that confidence in optimal interval timing is too low to make specific recommendations 2

In practice, maintain the standard 3-5 minute interval as recommended by current guidelines, ensuring early initial administration and consistent repeat dosing. 1, 3

Common Pitfalls to Avoid

• Never use high-dose epinephrine (0.1 mg/kg) IV/IO - associated with worse outcomes 1
• Do not delay epinephrine for vascular access - if IV/IO unavailable, use endotracheal route at higher dose (0.1 mg/kg) 2
• Do not exceed 1 mg maximum single dose regardless of patient weight 1
• Do not use doses <0.01 mg/kg - inadequate for achieving return of spontaneous circulation 2
• Do not substitute vasopressin - not recommended for routine use in pediatric cardiac arrest and associated with lower ROSC rates 1