What is the correct dose and frequency of epinephrine (adrenaline) administration for a pediatric patient in cardiac arrest with a history of acute kidney injury (Impaired renal function) and severe hyperkalemia?

Epinephrine Dosing in 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, using the 1:10,000 concentration (0.1 mg/mL), regardless of acute kidney injury or hyperkalemia status. 1

Standard Dose Protocol

The dose remains 0.01 mg/kg IV/IO for all pediatric cardiac arrest patients, including those with renal impairment and hyperkalemia. 1 This translates to 0.1 mL/kg of the 1:10,000 solution (0.1 mg/mL concentration). 1

• Maximum single dose is 1 mg regardless of patient weight 1
• Use IV or IO routes preferentially; these provide more predictable drug levels than endotracheal administration 1
• If endotracheal administration is necessary (no vascular access), use a higher dose of 0.1 mg/kg to compensate for reduced bioavailability 1

Dosing Frequency: Every 3-5 Minutes

Repeat epinephrine every 3-5 minutes throughout the resuscitation until return of spontaneous circulation (ROSC). 2, 1

The evidence on optimal dosing intervals is complex and somewhat contradictory:

• Avoid dosing more frequently than every 3 minutes: Very-low-certainty evidence suggests that intervals less than 3 minutes are associated with lower 12-month survival (adjusted OR 0.50; 95% CI, 0.24-1.06) compared to 3-5 minute intervals 2
• The 2020 International Consensus cannot make a firm recommendation about optimal subsequent dose intervals due to very low confidence in the evidence 2
• The 3-5 minute interval represents the safest approach balancing potential benefit with avoiding harm from excessive dosing 1

Critical Timing Considerations

For nonshockable rhythms (asystole, PEA), administer the initial epinephrine dose as early in the resuscitation as possible. 2 This is a weak recommendation based on very-low-certainty evidence, but early administration is associated with improved outcomes. 2

• For shockable rhythms (VF/pVT), no specific recommendation exists for timing of initial epinephrine 2
• Every minute of delay in the first epinephrine dose decreases survival in nonshockable cardiac arrest 1

High-Dose Epinephrine: Contraindicated

Do not use high-dose epinephrine (0.1 mg/kg or 100 mcg/kg). 1, 3 The highest quality randomized controlled trial demonstrated that high-dose epinephrine as rescue therapy resulted in significantly worse 24-hour survival compared to standard dosing (1/34 vs 7/34 survived; odds ratio for death 8.6; P=0.05). 3

• In asphyxial arrest specifically, high-dose epinephrine was particularly harmful: 0/12 survived at 24 hours with high-dose vs 7/18 with standard dose (P=0.02) 3
• High-dose epinephrine does not improve return of spontaneous circulation rates 3
• The American Academy of Pediatrics explicitly states that high-dose epinephrine is associated with reduced 24-hour survival and does not improve neurologic outcomes 1

Special Considerations for Renal Impairment and Hyperkalemia

The standard epinephrine dose does not require adjustment for acute kidney injury or hyperkalemia during cardiac arrest. The immediate life-threatening nature of cardiac arrest supersedes concerns about epinephrine's potential renal effects or exacerbation of hyperkalemia.

• While epinephrine dosing (both total number and frequency) has been identified as a risk factor for post-arrest acute kidney injury 4, this does not justify withholding or reducing doses during active resuscitation
• Hyperkalemia itself is a potentially reversible cause of cardiac arrest and should be treated concurrently with calcium chloride or calcium gluconate, sodium bicarbonate, and other standard therapies 1
• The priority during cardiac arrest is achieving ROSC; renal protection strategies are secondary

Administration Technique

• Administer during ongoing chest compressions—do not interrupt compressions for drug administration 1
• Prepare doses in advance to minimize delays 1
• Verify concentration before administration: confusion between 1:1,000 and 1:10,000 concentrations can be fatal 1
• Follow each dose with a saline flush to ensure drug delivery 1

Common Pitfalls to Avoid

• Do not dose more frequently than every 3 minutes in an attempt to improve outcomes—this may worsen survival 2, 1
• Do not escalate to high-dose epinephrine if standard doses fail—continue standard dosing 1, 3
• Do not delay the first dose in nonshockable rhythms while establishing "perfect" access—use IO if IV access is delayed 1
• Do not reduce or withhold epinephrine due to concerns about renal function or hyperkalemia during active cardiac arrest—achieving ROSC is the priority