Adrenaline Infusion Guidelines

Indications and Administration

Adrenaline infusions are indicated for severe anaphylaxis unresponsive to intramuscular epinephrine and for hypotension associated with septic shock, according to the American Academy of Allergy, Asthma, and Immunology 1, 2, 3
The American Heart Association recommends intravenous epinephrine administration only during cardiac arrest or to profoundly hypotensive patients who have failed to respond to intravenous volume replacement and several injected doses of epinephrine 1

For anaphylaxis, prepare a 1:100,000 solution by adding 1 mg (1 mL) of epinephrine in 100 mL saline, as recommended by the American Academy of Allergy, Asthma, and Immunology 1
Infuse at a rate of 1 to 4 μg/min (15 to 60 drops per minute with a microdrop apparatus), increasing to a maximum of 10.0 μg/min for adults and adolescents, according to the American Academy of Allergy, Asthma, and Immunology 1
For children, administer 0.01 mg/kg (0.1 mL/kg of a 1:10,000 solution; maximum dose, 0.3 mg), as recommended by the American Academy of Pediatrics 1

Continuous hemodynamic monitoring is essential when administering intravenous epinephrine, according to the American Society of Anesthesiologists 1, 2
For patients requiring dopamine or epinephrine, blood pressure should be measured frequently at intervals of 5-15 minutes, as recommended by the Society of Critical Care Medicine 3
In patients receiving beta-blockers who develop anaphylaxis, consider glucagon 1-5 mg IV infusion over 5 minutes if hypotension persists despite epinephrine, according to the European Society of Medical Oncology 4, 5

For intravenous administration in children in acute settings, prepare a syringe containing 1 mL of 1:10,000 adrenaline for each 10 kg body weight, as recommended by the Association of Paediatric Anaesthetists 6
Titrate to response, starting with one-tenth of the contents of the syringe, according to the Association of Paediatric Anaesthetists 6

Intravenous epinephrine carries significant risk of potentially lethal arrhythmias and should be used only when absolutely necessary, according to the American Heart Association 1, 2
Epinephrine has a short half-life, requiring continuous infusion rather than bolus administration for sustained effect, as noted by the American Society of Anesthesiologists 2, 7
Extravasation can cause substantial skin necrosis; frequently check the infusion site, according to the Society of Critical Care Medicine 3

Adrenaline infusions should be initiated when multiple bolus doses fail to maintain adequate blood pressure or when severe, refractory anaphylaxis or cardiac arrest requires sustained vasopressor support, as recommended by the American Society of Anesthesiologists 8
For children requiring intravenous adrenaline in acute settings, prepare 1 mL of 1:10,000 adrenaline for each 10 kg body weight, starting with 1 μg/kg and titrating to response, according to the American Academy of Pediatrics 8

Preferentially infuse adrenaline through a central venous catheter, but peripheral venous or intraosseous access may be used if central access is unavailable, as suggested by the Society of Critical Care Medicine 9
Frequently check the infusion site for extravasation, as substantial skin necrosis may occur, and monitor blood pressure and heart rate every 5-15 minutes during infusion, as recommended by the American Heart Association 9

For cardiac arrest, the standard dose remains 1 mg intravenous adrenaline every 3-5 minutes, though high-dose regimens have not demonstrated improved survival or neurological outcomes in humans, according to the European Resuscitation Council 10

If blood pressure does not recover despite adrenaline infusion, consider alternative vasopressors such as metaraminol or norepinephrine, as recommended by the Society of Critical Care Medicine 8, 9
Norepinephrine should be preferred over epinephrine when available in septic shock due to less lactic acidosis, according to the Surviving Sepsis Campaign 9

The American Academy of Pediatrics recommends starting an adrenaline infusion at 0.1 mcg/kg/min and titrating upward to 1.0 mcg/kg/min based on blood pressure response, with doses occasionally reaching 5 mcg/kg/min in severe cases 11
For pediatric patients, the infusion should be prepared to achieve a concentration that allows precise dosing based on weight 11
The usual effective range for adrenaline infusion is 0.1–1.0 mcg/kg/min, though doses up to 5 mcg/kg/min may be necessary in severe distributive shock 11

The American Heart Association recommends giving 1 mg IV/IO boluses of adrenaline every 3–5 minutes during cardiac arrest, instead of continuous infusion 12, 13, 14
The pediatric dose of adrenaline for cardiac arrest is 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO, maximum 1 mg per dose, repeated every 3–5 minutes 12, 13
High-dose epinephrine regimens have not improved survival or neurological outcomes and are not recommended 15, 16, 14

The British Medical Journal suggests establishing IV access, preferably central venous, for adrenaline administration, and never administering continuous infusions via endotracheal tube 15, 16, 12
Continuous cardiac monitoring is mandatory during adrenaline infusion, as it can cause tachyarrhythmias, ventricular ectopy, and potentially lethal arrhythmias 11

The American Academy of Pediatrics warns against confusing 1:1000 and 1:10,000 concentrations of adrenaline, and recommends verifying the concentration before drawing up doses 11
Extreme caution should be exercised when giving adrenaline to patients on beta-blockers, or those with cocaine/sympathomimetic drug intoxication, and consider glucagon 1–5 mg IV over 5 minutes for beta-blocker patients with refractory hypotension 15, 16
The European Heart Journal recommends flushing peripheral IV lines with 20 mL of normal saline after each bolus dose to ensure drug delivery to central circulation 15, 16, 14