IV Epinephrine Dosing in Anaphylactic Shock

Initial Management and Route Selection

The American Heart Association recommends an initial dose of intravenous (IV) epinephrine in anaphylactic shock of 0.05 to 0.1 mg (0.1 mg/mL or 1:10,000 concentration) 1, 2, 3
Intramuscular (IM) epinephrine (0.3-0.5 mg of 1:1000 concentration) is the preferred first-line treatment for anaphylaxis due to ease of administration, effectiveness, and safety profile 3
IV epinephrine should only be considered when an IV line is already in place and in specific circumstances, such as cardiac arrest from anaphylaxis, profound hypotension unresponsive to IV fluids and IM epinephrine, or failure to respond to several injected doses of epinephrine 3, 4

When using IV bolus, administer 0.05 to 0.1 mg (5-10% of the cardiac arrest dose) 1, 2, 3
The American Heart Association guidelines recommend this dose for anaphylactic shock 2
The medication should be given slowly over several minutes to minimize adverse effects 5
IV infusion is a reasonable alternative to repeated IV boluses, allowing for careful titration and avoidance of epinephrine overdose 1, 2
Two recommended preparation methods for continuous infusion are:

Continuous hemodynamic monitoring is essential when administering IV epinephrine 1, 4
In settings without advanced monitoring, use every-minute blood pressure measurements, continuous pulse monitoring, and ECG monitoring if available 4
Potential adverse effects include tachyarrhythmias/ectopic beats, hypertension, risk of potentially lethal arrhythmias, and extravasation causing severe skin injury 3, 4, 5

For patients with concomitant β-blocker therapy, consider glucagon (1-5 mg IV over 5 minutes followed by infusion) 5
For refractory hypotension despite epinephrine, consider alternative vasopressors such as dopamine (2-20 μg/kg/min) 5

Administering IV epinephrine too rapidly, which increases risk of adverse cardiovascular effects 5
Delaying epinephrine administration while focusing on second-line treatments (antihistamines, steroids) 3
Using incorrect concentration (1:1000 vs. 1:10,000) for IV administration 5
Failing to provide continuous hemodynamic monitoring during IV epinephrine administration 4