What is the protocol for administering an epinephrine (adrenaline) push dose?

From the Guidelines

Epinephrine push dose is recommended at a concentration of 10 mcg/mL, administered 0.5-2 mL (5-20 mcg) IV push every 2-5 minutes as needed to maintain blood pressure, based on the most recent and highest quality study available 1. To prepare push-dose epinephrine, take 1 mL of cardiac epinephrine (1:10,000 or 0.1 mg/mL) and dilute it with 9 mL of normal saline in a 10 mL syringe. The resulting solution contains 10 mcg/mL of epinephrine. This dosing provides rapid but short-acting alpha and beta adrenergic effects to increase heart rate, contractility, and peripheral vascular resistance. Push-dose epinephrine should be used as a bridge to more definitive therapy such as vasopressor infusions. Label the syringe clearly to avoid medication errors, and monitor the patient closely for tachycardia, hypertension, and arrhythmias. This approach is particularly useful in emergency situations like peri-intubation hypotension, anaphylaxis, or when immediate hemodynamic support is needed before vasopressor infusions can be prepared, as supported by the American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1. Key considerations include:

• Administering epinephrine every second cycle of CPR after the initial dose may also be reasonable 1.
• Earlier epinephrine administration is associated with improved outcomes in patients with nonshockable rhythms 1.
• High-dose epinephrine has not been shown to improve survival to discharge or longer-term outcomes compared to standard-dose epinephrine 1. The most recent study from 2024 1 provides the strongest evidence for the use of epinephrine push dose in emergency situations, and its recommendations should be prioritized in clinical practice.

From the FDA Drug Label

1. DOSAGE & ADMINISTRATION 2.1 General Considerations Inspect visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
2. 2 Hypotension associated with Septic Shock Dilute 10 mL (1 mg) of epinephrine from the syringe in 1,000 mL of 5 percent dextrose solution or 5 percent dextrose and sodium chloride solution to produce a 1 mcg per mL dilution.

The FDA drug label does not answer the question about Epinephrine Push Dose.

From the Research

Epinephrine Push Dose Overview

• Epinephrine push dose is a method used to temporarily resolve hypotension during critical care transport 2
• The typical dose is 10-20 µg of 1:100,000 epinephrine given intravenously every 2 min until the systolic blood pressure (SBP) is at least 90 mmHg, or the mean arterial pressure (MAP) is 65 mmHg or greater 2

Efficacy and Safety

• Studies have shown that push-dose epinephrine can be an effective method of temporarily resolving hypotension during critical care transport, with close adherence to established protocols and rare adverse events 2
• However, other studies have suggested that push-dose norepinephrine may be a better choice, with demonstrated safety and efficacy in various shock states 3
• A comparison of push-dose phenylephrine and epinephrine in the emergency department found that epinephrine provided a greater increase in systolic blood pressure, but dosing errors occurred more frequently with epinephrine 4

Combination Therapy

• The use of vasopressin, steroids, and epinephrine has been shown to improve survival to hospital discharge with favorable neurological status in patients with cardiac arrest requiring vasopressors 5
• However, another study found that vasopressin administered with epinephrine did not increase the rate of return of spontaneous circulation in out-of-hospital cardiac arrest 6

Key Findings

• Push-dose epinephrine can be effective in resolving hypotension during critical care transport, but further research is needed to validate these findings and establish optimal dosing 2
• Push-dose norepinephrine may be a better choice in certain situations, with demonstrated safety and efficacy in various shock states 3
• Combination therapy with vasopressin, steroids, and epinephrine may improve survival to hospital discharge with favorable neurological status in patients with cardiac arrest requiring vasopressors 5