Adrenaline (epinephrine) Intravenous for Adults

Who can administer

Administration RESTRICTED - see Appendix 1

Important information

• Central line administration: administration by infusion in specialist units only - (critical care only)
• Peripheral line administration (restricted use - Critical Care, Outreach ONLY)
• Resuscitation use: any area
• Infusion route is an unlicensed method of administration
• For Y-site compatibility see below

Available preparations

Adrenaline 1mg in 1mL ampoule (1:1000) (Mercury)

Adrenaline 1mg in 10mL pre-filled syringe (1:10,000) (Aurum)

Adrenaline 100 microgram in 1mL ampoule (Martindale)- for use in neonates

Reconstitution

Pre-filled syringe

• Already in solution

Ampoule

• Already in solution
• Dilute further prior to administration
• Draw up using a 5 micron filter needle

Infusion fluids

Glucose 5% (preferred ^{(ref 3)}) or Sodium chloride 0.9%

Methods of intravenous administration

Bolus intravenous injection

• Resuscitation: as per GUH guidelines
• Pre-filled syringes are used as supplied
• Ampoules are to be diluted before use

Continuous intravenous infusion (using an electronically controlled infusion device)

• Central line administration
  • Prepare a solution containing either 3mg in 50mL, or 6mg in 50mL
  • A 3mg per 50mL solution contains 60 micrograms per mL
  • A 6mg per 50mL solution contains 120 micrograms per mL
  • Administer at a suitable rate, titrated to response - see 'dose' below

• Peripheral line administration^{(ref 1)} (restricted use - Critical Care, Outreach ONLY)
  • Adrenaline 1mg in 1mL ampoule
  • Prepare a solution containing 4mg in 250ml (16 micrograms per mL)
  • Administer at a suitable rate, titrated to response - see 'dose' below

Dose in adults

Bolus intravenous injection: as per resuscitation guidelines

• Pre-filled syringes are used as supplied
• Ampoules are to be diluted before use

Continuous intravenous infusion - CENTRAL LINE (Critical Care only) ^{(ref 2)}

• Initial rate: 1 microgram per minute, titrated to effect

Continuous intravenous infusion - PERIPHERAL LINE (Restricted use - Critical Care, Outreach ONLY)

• Anaphylaxis (refractory to IM adrenaline) ^{(ref 2,4)}
  • Initial rate advised at 0.1microgram per kilogram per minute
  • Increase rate every two to three minutes by 0.05 mcg/kg/minute until BP and perfusion improve. (see table below for mL/hour volume rate for microgram/kg/minute dosing)
  • See Table 1 below and also Guideline for the use of vasopressor agents by peripheral infusion, UHG

Table 1: Peripheral line (restricted use - Critical Care, Outreach ONLY) Indication: Anaphylaxis (refractory to IM adrenaline) (ref 2,4) Rate (mL/hour) for microgram/kg/min doses using 4mg/250mL infusion
Dosage (microgram/kg/minute)	50kg patient	75kg patient	100kg patient
0.1microgram/kg/minute	19 mL/hr	28 mL/hr	38 mL/hr
0.2microgram/kg/minute	38 mL/hr	56 mL/hr	75 mL/hr
0.3microgram/kg/minute	56 mL/hr	84 mL/hr	113 mL/hr
0.4microgram/kg/minute	75 mL/hr	113 mL/hr	150 mL/hr
0.5microgram/kg/minute	94 mL/hr	141 mL/hr	188 mL/hr
Doses rounded for convenience
Peripheral venous access (ref 1): should ideally be of size 20G or more be sited proximal to the wrist in the arm avoid sites of flexion in awake patients avoid sites requiring more than one venepuncture there should be a return of blood following insertion and flush easily with 5-10mL of 0.9% sodium chloride

Monitoring

• Monitor infusion site frequently - extravasation may cause local tissue necrosis
• Monitor blood pressure continuously
• Monitor blood glucose whilst on continuous infusion ^{(ref 3)}
• Peripheral administration: a staff member competent in the administration of peripheral vasopressor MUST supervise the patient

Further information

• If PERIPHERAL line extravasation occurs, see Guideline for the use of vasopressor agents by peripheral intravenous infusion, UHG
• If CENTRAL line extravasation occurs, give phentolamine subcutaneously (into site of extravasation) 5 to 10mg in 10 to 20mL Sodium chloride 0.9% ^{(ref 2)}

Storage

Store below 25⁰C

References

Adrenaline 1: 1,000 (Mercury) SPC August 2018

Adrenaline 1:10,000 (Martindale)

1: Adult Critical Care Patients. Version 1.1 November 2022 (interim update)
Available from: Intensive Care Society | Vasopressor Agents in Adult ICU (ics.ac.uk) Accessed: 11th July 2023

2: UpToDate (Adrenaline)- accessed online 28th December 2023

3: Injectable medicines guide, Accessed via Medusa 28th December 2023

4: Guideline for the use of vasopressor agents by peripheral infusion, UHG, January 2024

Therapeutic classification

Adrenergic agent/inotrope