Example of preparation of epinephrine infusion for refractory symptoms of anaphylaxis (adult patient) for emergency/critical care units | ||
Final concentration: Epinephrine 4 micrograms/mL | ||
Preparation | ||
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Administration | ||
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Adult infusion dose | Administration rate for infusion pump to deliver adult dose shown | |
micrograms per minute | mL per minute | mL per hour |
1 | 0.25 | 15 |
2 | 0.5 | 30 |
3 | 0.75 | 45 |
4 | 1 | 60 |
5 | 1.25 | 75 |
6 | 1.5 | 90 |
7 | 1.75 | 105 |
8 | 2 | 120 |
9 | 2.25 | 135 |
10 | 2.5 | 150 |
11 | 2.75 | 165 |
12 | 3 | 180 |
13 | 3.25 | 195 |
14 | 3.5 | 210 |
15 | 3.75 | 225 |
16 | 4 | 240 |
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Albuterol – For bronchospasm resistant to IM epinephrine, give albuterol 2.5 mg inhaled via nebulizer. Dilute in saline if using a concentrated albuterol solution (≥0.5%). Repeat, as needed. | ||
H1 antihistamine – Consider giving diphenhydramine 1 mg/kg (maximum 50 mg IV, over 5 minutes) or cetirizine (children aged 6 months to 5 years can receive 2.5 mg IV, those 6 to 11 years of age can receive 5 or 10 mg IV, over 2 minutes). | ||
H2 antihistamine – Consider giving famotidine 0.25 mg/kg (maximum 20 mg) IV, over at least 2 minutes. | ||
Glucocorticoid – Consider giving methylprednisolone 1 mg/kg (maximum 125 mg) IV. | ||
Monitoring – Continuous noninvasive hemodynamic monitoring and pulse oximetry monitoring should be performed. Urine output should be monitored in patients receiving IV fluid resuscitation for severe hypotension or shock. | ||
Treatment of refractory symptoms: | ||
Epinephrine infusion¶ – In patients with inadequate response to IM epinephrine and IV saline, give epinephrine continuous infusion at 0.1 to 1 microgram/kg/minute, titrated to effect. | ||
Vasopressors¶ – Patients may require large amounts of IV crystalloid to maintain blood pressure. Some patients may require a second vasopressor (in addition to epinephrine). All vasopressors should be given by infusion pump, with the doses titrated continuously according to blood pressure and cardiac rate/function monitored continuously and oxygenation monitored by pulse oximetry. | ||
Glucagon – Patients on beta blockers may not respond to epinephrine and can be given glucagon 20 to 30 micrograms/kg (maximum 1 mg) IV over 5 minutes. Rapid administration of glucagon can cause vomiting. |
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