Epinephrine Infusion Dosing for Shock
For septic shock in adults, start epinephrine infusion at 0.05-0.1 mcg/kg/min and titrate up to 2 mcg/kg/min to achieve target MAP, typically ≥65 mmHg 1.
Adult Dosing
Septic/Distributive Shock
- Initial rate: 0.05 mcg/kg/min IV infusion
- Titration: Increase by 0.05-0.2 mcg/kg/min every 10-15 minutes
- Maximum: 2 mcg/kg/min (though doses up to 5 mcg/kg/min are sometimes necessary) 1, 2
- Target: MAP ≥65 mmHg with adequate end-organ perfusion 3
Anaphylactic Shock
When IV epinephrine is required (after failed IM doses and volume resuscitation):
- Preparation: 1 mg epinephrine in 250 mL D5W = 4 mcg/mL concentration
- Initial rate: 1-4 mcg/min (0.015-0.06 mL/min or 15-60 drops/min with microdrop)
- Maximum: 10 mcg/min for adults 4
- Alternative preparation: 1 mg in 100 mL saline (1:100,000), infuse at 30-100 mL/h (5-15 mcg/min) 5
Critical caveat: IV epinephrine in anaphylaxis should only be used when patients remain profoundly hypotensive despite adequate fluid resuscitation (1-2L crystalloid) and multiple IM epinephrine doses (0.3-0.5 mg IM every 5-15 minutes) 4. Continuous hemodynamic monitoring is essential due to arrhythmia risk.
Pediatric Dosing
Septic/Distributive Shock
- Initial rate: 0.1 mcg/kg/min IV infusion
- Titration: Increase to clinical effect
- Maximum: 1.0 mcg/kg/min (up to 5 mcg/kg/min may be necessary) 2
Anaphylactic Shock
- Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution; maximum 0.3 mg) 4
- "Rule of 6" alternative: 0.6 × body weight (kg) = mg of epinephrine diluted to 100 mL saline; then 1 mL/h delivers 0.1 mcg/kg/min 4
Cardiac Arrest (Pediatric)
Preparation and Administration
Standard concentration for shock: Add 1 mg (1 mL of 1:1000) epinephrine to 250 mL D5W or NS to yield 4 mcg/mL 4, 1. Avoid saline-only solutions when possible; use D5W or D5W with sodium chloride 1.
Infusion pump preferred for precise titration. If unavailable, use microdrop apparatus (60 drops/mL) 4.
Vascular access: Use large veins when possible. Avoid leg veins in elderly or those with vascular disease. Extravasation causes severe tissue injury—treat with phentolamine 0.1-0.2 mg/kg (max 10 mg) diluted in 10 mL NS injected intradermally at site 2.
Monitoring Requirements
- Continuous: ECG, arterial line for beat-to-beat BP monitoring when available
- Frequent: BP and pulse every 1-2 minutes during titration 4
- Serial markers: Lactate clearance, urine output, mental status, skin perfusion, ScvO2/SvO2 7, 3
- Weaning: After hemodynamic stabilization, decrease incrementally every 30 minutes over 12-24 hours 1
Clinical Context by Shock Type
Distributive shock (sepsis): Norepinephrine remains first-line; epinephrine is second-line when additional agent needed or as single agent when myocardial depression present 3. Epinephrine increases cardiac output without significantly affecting systemic vascular resistance at lower doses 8.
Cardiogenic shock: Use cautiously—increases myocardial oxygen consumption and arrhythmia risk. Consider only after inotropes (dobutamine) with persistent hypotension 7.
Anaphylactic shock: Epinephrine is cornerstone therapy, but IM route is preferred initially. Reserve IV infusion for refractory cases 5.
Key Pitfalls
- Do not use IV epinephrine as first-line in anaphylaxis—multiple fatalities attributed to injudicious IV use 4. Always attempt IM dosing first (0.3-0.5 mg IM into lateral thigh).
- Avoid bolus IV epinephrine in anaphylaxis unless cardiac arrest—use infusion for titration 5
- Monitor for tachyarrhythmias, hypertension, and tissue ischemia at higher doses
- Ensure adequate volume resuscitation first—epinephrine is not a substitute for fluid resuscitation 3
- Check concentration carefully—1:1000 (1 mg/mL) vs 1:10,000 (0.1 mg/mL) confusion causes dosing errors 2