Preparing an Epinephrine Infusion in Pediatric Patients
To prepare an epinephrine drip for a pediatric patient, multiply 0.6 × the patient's weight in kilograms to determine the number of milligrams of epinephrine, then add this amount to normal saline or D5W to make a total volume of 100 mL; this yields a concentration where 1 mL/hour delivers 0.1 mcg/kg/min. 1
Standard Preparation Method ("Rule of 6")
The most practical approach for pediatric epinephrine infusions uses the "Rule of 6" formula 1:
- Calculate the dose: 0.6 × patient's weight (kg) = milligrams of epinephrine needed 1
- Add to diluent: Mix the calculated milligrams into normal saline or D5W to achieve a total volume of 100 mL 1
- Resulting concentration: At this dilution, 1 mL/hour = 0.1 mcg/kg/min 1
Example Calculation
For a 20 kg child:
- 0.6 × 20 kg = 12 mg of epinephrine
- Add 12 mg to normal saline/D5W for total volume of 100 mL
- Infusion rate of 1 mL/hour = 0.1 mcg/kg/min 1
Alternative Standard Concentration
An alternative preparation method creates a fixed concentration 1, 2:
- Add 1 mg (1 mL) of 1:1,000 epinephrine to 250 mL of D5W 1, 2
- This yields a concentration of 4.0 mcg/mL 1, 2
- Infusion rate must then be calculated based on patient weight and desired mcg/kg/min 1
Initial Dosing Parameters
- Starting dose: 0.1 mcg/kg/min 1
- Therapeutic range: 0.1-1.0 mcg/kg/min 1
- Maximum dose: Up to 5 mcg/kg/min may be necessary in severe refractory cases 1
- Titration: Increase incrementally based on clinical response, monitoring blood pressure, heart rate, and perfusion markers every 5-15 minutes 1
Critical Administration Considerations
Route of Administration
- Central venous access is strongly preferred to minimize extravasation risk and tissue necrosis 1
- Peripheral IV or intraosseous access may be used temporarily during initial resuscitation if central access is unavailable 1
- For cardiac arrest specifically, IV/IO administration is preferable to endotracheal tube administration 3
Solution Preparation Safety
- Always visually inspect the epinephrine solution before preparation 1, 4
- Discard if not clear and colorless or if it contains particulate matter or crystals 1, 4
- Do not use solutions that are discolored or cloudy 4
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 to prevent tissue necrosis 1
Cardiac Arrest Dosing (Different from Infusion)
For pediatric cardiac arrest, the dosing differs significantly from continuous infusion 3:
- Initial dose: 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 solution) 3
- Maximum single dose: 1 mg 3
- Timing: Administer within 5 minutes from start of chest compressions 3
- Repeat dosing: Every 3-5 minutes until return of spontaneous circulation 3
- Endotracheal dose (if IV/IO unavailable): 0.1 mg/kg (10 times the IV dose, using 1:1,000 concentration) 3
Common Pitfalls to Avoid
- Concentration confusion: Never confuse 1:1,000 (1 mg/mL) with 1:10,000 (0.1 mg/mL) concentrations, as this results in 10-fold dosing errors 2
- Inadequate volume resuscitation: Address hypovolemia with aggressive crystalloid boluses concurrent with epinephrine administration, as vasoconstriction without adequate volume causes severe organ hypoperfusion 1
- Alkaline solution mixing: Do not mix epinephrine with sodium bicarbonate or other alkaline solutions in the IV line, as epinephrine is inactivated in alkaline environments 1
- Measurement errors: Volumes less than 0.1 mL cannot be accurately measured with standard equipment, increasing risk of dosing errors 5