Preparing "Dirty Epinephrine" for Emergency Use

Preparation and Administration

The British Journal of Anaesthesia recommends preparing "dirty epinephrine" by diluting standard 1:1,000 (1 mg/mL) epinephrine with normal saline at the bedside to create a 1:10,000 (0.1 mg/mL) concentration for intravenous bolus administration in perioperative anaphylaxis and other emergency situations 1
The American College of Anaesthesiologists is not mentioned, however, the British Journal of Anaesthesia guidelines suggest that to prepare dirty epinephrine, draw up 1 mL of 1:1,000 epinephrine (1 mg) and add 9 mL of normal saline to create 10 mL of 1:10,000 solution (0.1 mg/mL), yielding a final concentration of 100 mcg/mL, which allows for precise titration of small IV bolus doses 1
The British Journal of Anaesthesia guidelines state that prefilled syringes of 100 mcg/mL epinephrine are commercially available in some countries (UK, France, USA) but not universally 2

For Grade II Perioperative Anaphylaxis (Moderate Hypotension or Bronchospasm), the initial IV bolus is 20 mcg (0.2 mL of dirty epinephrine), administered when vasopressor or bronchodilator is clinically indicated, with escalation to 50 mcg if unresponsive at 2 minutes, and simultaneous administration of crystalloid 500 mL rapid bolus, repeated as needed 1
For Grade III Perioperative Anaphylaxis (Life-Threatening Hypotension or Bronchospasm), the initial IV bolus is 50-100 mcg (0.5-1.0 mL of dirty epinephrine), with administration of 50 mcg if no other vasopressors/bronchodilators have been administered, and 100 mcg if patient is unresponsive to other vasopressors/bronchodilators, with escalation to 200 mcg if unresponsive at 2 minutes, and administration of crystalloid 1 L as rapid bolus, repeated if inadequate response 1

The British Journal of Anaesthesia guidelines emphasize the importance of addressing hypovolemia with aggressive crystalloid boluses concurrent with epinephrine administration, as vasoconstriction without adequate volume resuscitation causes severe organ hypoperfusion despite "normal" blood pressure 1
Familiarity with dilution methods must be part of perioperative anaphylaxis training and included in cognitive aids, with the preparation practiced regularly, not attempted for the first time during an emergency 2

A 1mg/mL epinephrine ampule is already a 1:1000 concentration, meaning 1 gram per 1000 mL, which equals 1 mg per 1 mL, and requires no dilution for use 3
No preparation or dilution is needed—the ampule is ready to use as-is 3

For anaphylaxis, the American Academy of Pediatrics recommends 0.3-0.5 mg (0.3-0.5 mL) for adults, or 0.01 mg/kg (0.01 mL/kg) for children, administered intramuscularly in the anterolateral thigh 3
For severe asthma exacerbation, 0.01 mg/kg (maximum 0.3-0.5 mg) subcutaneously, repeated every 20 minutes up to 3 doses, is recommended 3
For croup/laryngotracheobronchitis, 0.5 mL/kg (maximum 5 mL) administered by nebulizer is suggested 3
For endotracheal administration during resuscitation, 0.1 mg/kg (0.1 mL/kg) for older infants/children (maximum 10 mg) is recommended 3

It is crucial not to confuse 1:1000 with 1:10,000 concentration to avoid administering incorrect doses 3
Using 1:1000 intravenously when 1:10,000 is indicated would deliver 10 times the intended dose 3

To create 1:10,000 epinephrine from a 1:1000 ampule, take 1 mL of the 1:1000 solution (1 mg) and add 9 mL of normal saline to create 10 mL of 1:10,000 solution (0.1 mg/mL) 3

The American Heart Association recommends a standard dose of 1 mg IV/IO every 3-5 minutes during active resuscitation until return of spontaneous circulation (ROSC) or termination of efforts 4
For cardiac arrest, administer 1 mg (10 mL of 1:10,000 or 0.1 mg/mL solution) IV push every 3-5 minutes, prepared as 1 mg in 10 mL (1:10,000 concentration = 0.1 mg/mL) for IV push administration 5
Flush with at least 5 mL normal saline after each dose to ensure drug delivery into central circulation 5
If IV/IO access is unavailable, the endotracheal dose is 0.1 mg/kg (10 times the IV dose, using 1:1000 concentration), though this route is less effective and associated with worse outcomes 5

For anaphylactic shock with IV access, use 0.05-0.1 mg (50-100 mcg) IV push, which is 5-10% of the cardiac arrest dose, administered every 2-5 minutes as needed for persistent hypotension or bronchospasm despite intramuscular epinephrine 4

Administer epinephrine into a large vein whenever possible, and central venous access is strongly preferred for continuous infusions to minimize extravasation risk 4
If extravasation occurs, immediately infiltrate 5-10 mg phentolamine diluted in 10-15 mL saline at the site to prevent tissue necrosis 4
Do not mix epinephrine with sodium bicarbonate or alkaline solutions in the IV line, as epinephrine is inactivated in alkaline environments 4
For anaphylaxis, intramuscular remains the preferred initial route (0.3-0.5 mg in anterolateral thigh); IV route is reserved for refractory cases with established IV access 4

For cardiac arrest in pediatric patients, the recommended dose is 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000), with a maximum of 1 mg per dose 5
The endotracheal dose for pediatric patients is 0.1 mg/kg (0.1 mL/kg of 1:1000), with a maximum of 2.5 mg 5

The American Academy of Allergy, Asthma, and Immunology recommends preparing a 1:250,000 solution by adding 1 mg (1 mL) of 1:1000 epinephrine to 250 mL of D5W for continuous IV infusion, yielding 4.0 mcg/mL, infused at 1-4 mcg/min 6