What is the maximum dose of adrenaline (epinephrine) per kilogram per minute in a pediatric patient?

Maximum Dose of Adrenaline (Epinephrine) in Pediatric Patients

For continuous infusion in pediatric shock after volume resuscitation, the maximum dose of adrenaline is 5 mcg/kg/min, though typical dosing ranges from 0.1-1.0 mcg/kg/min. 1

Standard Dosing Range for Continuous Infusion

• Start at 0.1 mcg/kg/min and titrate to desired clinical effect 1
• The typical therapeutic range is 0.1-1.0 mcg/kg/min for most pediatric patients with continued shock after volume resuscitation 1
• Maximum doses up to 5 mcg/kg/min are sometimes necessary in exceptional circumstances 1

Context-Specific Dosing

For Cardiopulmonary Resuscitation (Bolus Dosing)

• Standard dose: 0.01 mg/kg of 1:10,000 solution IV/IO (maximum 1 mg), repeated every 3-5 minutes 1
• Newborn infants: 0.01-0.03 mg/kg of 1:10,000 solution 1
• High-dose epinephrine (0.1 mg/kg) is no longer recommended for routine use in resuscitation, though it may be considered in exceptional circumstances such as β-blocker poisoning 1

For Anaphylaxis (Intramuscular/Subcutaneous)

• 0.01 mg/kg of 1:1000 solution (maximum 0.3-0.5 mg), repeated every 5-20 minutes 1
• The IM route is preferred for anaphylaxis 1
• Severe reactions may require IV epinephrine or continuous infusion 1

Critical Safety Considerations

Extravasation Risk

• IV infiltration can result in severe skin injury 1
• If extravasation occurs, inject phentolamine 0.1-0.2 mg/kg (up to 10 mg) diluted in 10 mL of 0.9% sodium chloride intradermally at the site to counteract dermal vasoconstriction 1

Concentration Selection

• Use extreme caution to ensure selection of the appropriate concentration for the route of administration and patient age/condition 1
• Epinephrine is available in two concentrations: 1:1000 (1 mg/mL) and 1:10,000 (0.1 mg/mL) 1
• To convert mg/kg dosage to mL/kg: 0.01 mg/kg = 0.1 mL/kg of 1:10,000 solution and 0.1 mg/kg = 0.1 mL/kg of 1:1000 solution 1

Dosing Algorithm by Clinical Scenario

For shock requiring continuous infusion:

1. Ensure adequate volume resuscitation first 1
2. Start at 0.1 mcg/kg/min 1
3. Titrate upward based on clinical response (blood pressure, perfusion, urine output) 1
4. Typical maximum: 1.0 mcg/kg/min 1
5. Absolute maximum in refractory cases: 5 mcg/kg/min 1

For cardiac arrest:

1. First dose: 0.01 mg/kg IV/IO of 1:10,000 solution (max 1 mg) 1
2. Repeat every 3-5 minutes as needed 1
3. Do not routinely escalate to high-dose (0.1 mg/kg) 1

For anaphylaxis:

1. First dose: 0.01 mg/kg IM of 1:1000 solution (max 0.3-0.5 mg) 1
2. Repeat every 5-20 minutes if needed 1
3. Consider continuous infusion if severe/refractory 1