Epinephrine Drip Dosing for Severe Allergic Reactions/Anaphylaxis
Preparation and Administration
- The American Academy of Allergy and Clinical Immunology recommends a starting dose for an epinephrine drip of 1-4 mcg/min, which can be titrated up to a maximum of 10 mcg/min based on clinical response and side effects 1, 2
- To prepare an epinephrine infusion, 1 mg (1 mL) of 1:1000 epinephrine can be added to 250 mL of D5W to yield a concentration of 4.0 mcg/mL, with an initial infusion rate of 1-4 mcg/min (15-60 drops/min with microdrop apparatus) 1, 3, 4
- An alternative method involves adding 1 mg (1 mL) of 1:1000 epinephrine to 100 mL of saline to create a 1:100,000 solution, with an initial infusion rate of 30-100 mL/hr (5-15 mcg/min) 1, 3, 4
Important Considerations and Precautions
- IV epinephrine should only be administered in specific circumstances, including cardiac arrest, profound hypotension unresponsive to IV fluids and IM epinephrine, and failure to respond to several injected doses of epinephrine 1, 2, 3, 4
- Continuous hemodynamic monitoring is essential when administering IV epinephrine, and in settings without hemodynamic monitoring, every-minute blood pressure measurements, continuous pulse monitoring, and ECG monitoring if available should be used 1, 3, 4, 5
Clinical Efficacy and Pediatric Dosing
- In clinical studies, most patients with anaphylaxis showed symptomatic improvement and systolic BP >90 mmHg within 5 minutes of epinephrine infusion 5, 6
- For children, the recommended dose is 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution; maximum 0.3 mg), with an alternative pediatric dosing using the "rule of 6" 1, 4, 5, 7
Potential Adverse Effects
- Tachyarrhythmias/ectopic beats, hypertension, and risk of potentially lethal arrhythmias are potential adverse effects of epinephrine infusion 1, 3, 7
- Extravasation can cause severe skin injury 7