How to calculate epinephrine dose in managing shock in pediatrics
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epinephrine dose pediatric shock vasopressor
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epinephrine pediatric septic shock dosing
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Epinephrine Dosing in Pediatric Shock
Epinephrine dosing in children depends on the type of shock and the clinical context. Below is a structured breakdown.
1. Septic Shock (Vasopressor Infusion)
Epinephrine is the first-line vasopressor for pediatric septic shock, particularly cold shock (the most common presentation in children).
| Parameter | Details |
|---|---|
| Starting dose | 0.05 mcg/kg/min IV/IO infusion |
| Titration | Increase as needed to reverse shock |
| Indication to start | Shock not improved after 60 mL/kg of isotonic fluid, or fluid overload develops with ongoing hypoperfusion |
| Route | Peripheral IV or intraosseous (central line not required initially) |
| Alternative first-line | Norepinephrine (equivalent evidence) |
"Most children with septic shock have cold shock and therefore epinephrine (0.05 mcg/kg/min) is the first-line vasopressor." - Rosen's Emergency Medicine, p. 3114
If no improvement with the initial agent, a second vasopressor should be added (though no evidence guides the specific second choice).
2. Cardiac Arrest (IV/IO Bolus)
For pulseless arrest (asystole, PEA, VF, pulseless VT, bradycardia unresponsive to CPR):
| Parameter | Details |
|---|---|
| Standard dose | 0.01 mg/kg IV or IO |
| Concentration | Use 0.1 mg/mL (1:10,000) formulation - give 0.1 mL/kg |
| Repeat dosing | Every 3-5 minutes during arrest |
| Maximum | No dose higher than 0.01 mg/kg is recommended; higher doses do NOT improve survival and may worsen outcomes |
| Endotracheal (ET) route | 0.1 mg/kg (10x the IV dose) - only if IV/IO unavailable |
"Doses of epinephrine greater than 0.01 mg/kg do not improve survival." - Rosen's Emergency Medicine, p. 3109
Note: Pre-filled code cart syringes can cause substantial overdoses in infants - verify weight-based dosing carefully.
3. Anaphylactic Shock (IM Injection)
| Parameter | Details |
|---|---|
| Dose | 0.01 mg/kg of 1:1,000 (1 mg/mL) epinephrine IM |
| Route | Intramuscular - anterolateral thigh (vastus lateralis) |
| Repeat | Every 5-10 minutes if needed (up to 30% of patients need more than 1 dose) |
| Auto-injector | EpiPen Jr (0.15 mg) for children < 30 kg; EpiPen (0.3 mg) for children > 30 kg |
"The dose of aqueous epinephrine... is 0.01 mg/kg of 1:1000 concentration IM for pediatric patients." - Rosen's Emergency Medicine, p. 2390
Subcutaneous and inhalation routes are no longer routinely recommended for anaphylaxis.
4. Post-Cardiac Arrest / Hemodynamic Support
For children who achieve return of spontaneous circulation (ROSC) but remain hemodynamically unstable:
| Parameter | Details |
|---|---|
| Dose | 0.02-0.2 mcg/kg/min infusion |
| Goal | Maintain systolic BP > 5th percentile for age |
5. Surgical / Perioperative Setting
For intraoperative cardiac arrest or severe bradycardia:
- Epinephrine 1-2 mcg/kg IV in small incremental boluses - Miller's Anesthesia, p. 30
Quick Reference Summary
| Clinical Scenario | Dose | Route | Formulation |
|---|---|---|---|
| Septic shock (infusion) | 0.05 mcg/kg/min (start) | IV/IO infusion | Any |
| Cardiac arrest (bolus) | 0.01 mg/kg q3-5 min | IV or IO | 1:10,000 (0.1 mL/kg) |
| Cardiac arrest (ET tube) | 0.1 mg/kg | Endotracheal | 1:1,000 |
| Anaphylaxis (IM) | 0.01 mg/kg | IM (anterolateral thigh) | 1:1,000 |
| Hemodynamic support | 0.02-0.2 mcg/kg/min | IV infusion | Any |
Key Clinical Pearls
- Cold shock (most common in pediatric sepsis): characterized by poor perfusion, cool extremities, prolonged cap refill - epinephrine is preferred over norepinephrine due to its combined alpha and beta effects.
- Warm shock: may also occur; norepinephrine is an equally valid choice.
- Dopamine was previously first-line but two RCTs showed epinephrine had more rapid shock resolution and lower mortality compared to dopamine.
- Always use weight-based dosing; pre-filled syringes risk overdose in small infants.
- Hydrocortisone (1-2 mg/kg, max 100 mg) may be added for catecholamine-resistant shock.
- Vascular access: peripheral IV or intraosseous (IO) is preferred for speed - central line is not necessary to initiate vasopressors.
Sources: Rosen's Emergency Medicine 10e, Miller's Anesthesia 10e, Barash Clinical Anesthesia 9e, Morgan & Mikhail Clinical Anesthesiology 7e.
How to calculate in how much ns
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Here is a complete guide to diluting epinephrine in NS for a pediatric infusion drip.
Preparing Epinephrine Infusion in NS for Pediatrics
What You Have (Standard Epinephrine Ampoules)
| Ampoule | Concentration |
|---|---|
| 1 mg/mL (1:1,000) | Most common stock ampoule |
| 0.1 mg/mL (1:10,000) | Pre-diluted (cardiac arrest syringes) |
Standard Dilution Methods
Method 1 - The "Rule of 6" (Weight-Based, Pediatric)
This is the classic bedside pediatric drip preparation method:
Mix: 0.3 mg × weight (kg) in 50 mL NS Running at 1 mL/hr = 0.1 mcg/kg/min
Example - 10 kg child:
- 0.3 × 10 = 3 mg epinephrine in 50 mL NS
- Running at 1 mL/hr → 0.1 mcg/kg/min
- Running at 0.5 mL/hr → 0.05 mcg/kg/min (starting dose for septic shock)
Method 2 - Standard Concentration (Pharmacy/ICU Method)
Use a fixed concentration and calculate the rate:
Common standard concentrations:
| Concentration | Preparation |
|---|---|
| 20 mcg/mL | 1 mg in 50 mL NS |
| 40 mcg/mL | 2 mg in 50 mL NS |
| 100 mcg/mL | 5 mg in 50 mL NS |
Rate formula:
Rate (mL/hr) = Dose (mcg/kg/min) × Weight (kg) × 60 ÷ Concentration (mcg/mL)
Example - 10 kg child, target dose 0.05 mcg/kg/min, using 20 mcg/mL:
- Rate = 0.05 × 10 × 60 ÷ 20
- Rate = 1.5 mL/hr
Step-by-Step Preparation (Bedside)
Using 1 mg/mL ampoule:
- Draw up the required mg of epinephrine into a syringe
- Make up to 50 mL total volume with NS
- Label clearly with: drug name, concentration (mcg/mL), date, time, patient weight
- Connect to syringe pump via dedicated IV line or IO
Quick Dose-to-Rate Reference (10 kg child, 20 mcg/mL drip)
| Dose | Rate |
|---|---|
| 0.05 mcg/kg/min (starting) | 1.5 mL/hr |
| 0.1 mcg/kg/min | 3 mL/hr |
| 0.2 mcg/kg/min | 6 mL/hr |
| 0.3 mcg/kg/min | 9 mL/hr |
Key Safety Points
- Never give undiluted 1 mg/mL epinephrine as an infusion
- Always use a syringe pump - never gravity drip for vasoactive drugs
- Can be given through peripheral IV or IO while awaiting central access
- Re-check rate calculation independently (two-nurse check)
- Label the syringe with the final concentration in mcg/mL
- Epinephrine is incompatible with sodium bicarbonate - use separate lines
If you give me the child's weight, I can calculate the exact preparation and drip rate for you.
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