What is the dosing for inotropic epinephrine (adrenaline)?

From the Guidelines

Epinephrine as an inotrope is typically dosed at 0.05-0.5 μg/kg/min when administered as a continuous IV infusion, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. Start at the lower end of the dosing range (0.05 μg/kg/min) and titrate upward based on hemodynamic response, targeting improved cardiac output and blood pressure. For preparation, add 1 mg of epinephrine to 250 mL of normal saline or D5W to create a concentration of 4 μg/mL. Epinephrine works by stimulating both alpha and beta adrenergic receptors, with beta-1 effects predominating at lower doses to increase cardiac contractility and heart rate. At higher doses (>0.1 μg/kg/min), alpha effects become more prominent, causing vasoconstriction. Some key points to consider when administering epinephrine include:

• Monitoring the patient closely for tachycardia, arrhythmias, myocardial ischemia, and tissue perfusion
• Ensuring central venous access for administration and maintaining continuous cardiac monitoring
• Administering epinephrine via an infusion pump with regular reassessment of hemodynamic parameters to guide dose adjustments
• Weaning should be done gradually to prevent rebound hypotension, as suggested by various studies 1. It is also important to note that the use of epinephrine in cardiac arrest is supported by the 2019 American Heart Association focused update on advanced cardiovascular life support 1. Additionally, other studies have discussed the use of epinephrine in various clinical scenarios, including anaphylaxis and cardiopulmonary resuscitation 1. However, the most recent and highest quality study, which is the 2016 ESC guidelines, recommends the dosing range of 0.05-0.5 μg/kg/min for epinephrine as an inotrope 1.

From the FDA Drug Label

2.2 Hypotension associated with Septic Shock The suggested dosing infusion rate of intravenously administered epinephrine is 0.05 mcg/kg/min to 2 mcg/kg/min, and is titrated to achieve a desired mean arterial pressure (MAP). The dosage may be adjusted periodically, such as every 10 – 15 minutes, in increments of 0.05 mcg/kg/min to 0. 2 mcg/kg/min, to achieve the desired blood pressure goal.

The dosing for Inotrope epi is as follows:

• Initial infusion rate: 0.05 mcg/kg/min to 2 mcg/kg/min
• Titration: adjust dosage periodically (every 10-15 minutes) in increments of 0.05 mcg/kg/min to 0.2 mcg/kg/min to achieve desired mean arterial pressure (MAP) 2

From the Research

Inotrope Epi Dosing

• The optimal dose of epinephrine is not known, but international guidelines recommend administration of 1 mg of intravenous epinephrine every 3-5 min during cardiac arrest 3.
• Reducing the dose of epinephrine administered during out-of-hospital cardiac arrest was not associated with a change in survival to hospital discharge or favorable neurological outcomes after OHCA 3.
• Inotrope score, which includes epinephrine dose, has been proposed as a marker of clinical outcome after adult heart transplantation, and high inotrope score post-HTx was associated with a higher risk of mortality and acute kidney injury 4.
• For most patients with shock, including cardiogenic or septic shock, norepinephrine is an appropriate choice as a first-line vasopressor, and low doses of epinephrine or dopamine may be used for inotropic support 5.
• The epinephrine dosing interval was not associated with 1-month neurologically favorable survival after OHCA, and neither shorter nor longer epinephrine dosing intervals were associated with neurologically favorable survival after OHCA 6.
• Among patients with post-resuscitation shock after out-of-hospital cardiac arrest, use of epinephrine was associated with higher all-cause and cardiovascular-specific mortality, compared with norepinephrine infusion 7.

Key Findings

• Epinephrine dosing interval and dose are important considerations in cardiac arrest treatment 3, 6.
• Inotrope score, including epinephrine dose, is associated with clinical outcomes after adult heart transplantation 4.
• Norepinephrine is a preferred vasopressor for shock treatment, with epinephrine or dopamine used for inotropic support 5.
• Epinephrine use is associated with higher mortality in post-resuscitation shock after out-of-hospital cardiac arrest 7.