Epinephrine IV 0.1 mg/mL (1:10,000) | Medication Reference

Bedside Snapshot

Drug Class: Endogenous catecholamine; nonselective α- and β-adrenergic agonist; vasopressor; inotrope
Core Uses: Workhorse vasopressor and inotrope for cardiac arrest and for shock with profound hypotension, especially when other agents are unavailable or insufficient
Cardiac Arrest (ACLS Adult): 1 mg IV/IO (10 mL of 0.1 mg/mL solution) every 3–5 minutes during CPR until ROSC or termination of resuscitation
Cardiac Arrest (Pediatric PALS): 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL solution), maximum 1 mg per dose, every 3–5 minutes
Continuous IV Infusion for Shock (Adult): Generally 0.02–0.5 mcg/kg/min, titrated to MAP and perfusion targets; many protocols use 0.05–0.5 mcg/kg/min as a common range; lower doses emphasize β effects (inotropy/chronotropy), higher doses more α-mediated vasoconstriction
Continuous IV Infusion for Anaphylactic Shock: Refractory to IM dosing—similar 0.05–0.5 mcg/kg/min range, titrated to blood pressure and symptom control, ideally in ICU setting
Push-Dose ("Bolus") Epinephrine: For peri-arrest hypotension (expert-level, off-label)—commonly prepared as 10–20 mcg per IV bolus (e.g., 1 mL of 10 mcg/mL solution) every 1–2 minutes as needed while setting up an infusion; requires strict protocols to avoid dosing errors
Onset: Essentially immediate IV; plasma half-life is only a few minutes, so effect dissipates quickly when infusion is decreased or stopped
Major IV Risks: Tachyarrhythmias, myocardial ischemia, severe hypertension, peripheral and visceral vasoconstriction with potential tissue ischemia, lactic acidosis, digital/mesenteric ischemia at high doses or prolonged use

Brand & Generic Names

Generic Name: Epinephrine (also known as adrenaline internationally)
Brand Names: Adrenalin, generics (0.1 mg/mL prefilled syringes, code-cart syringes, and dilutions per institution)

Medication Class

Endogenous catecholamine; nonselective α- and β-adrenergic agonist; vasopressor; inotrope

Pharmacology

Mechanism of Action – IV Epinephrine:

Epinephrine stimulates α1, α2, β1, and β2 adrenergic receptors
α1 effects: Vasoconstriction in arterioles and venules → increased systemic vascular resistance, improved diastolic pressure, and enhanced coronary and cerebral perfusion pressure during CPR
β1 effects: Increased heart rate, contractility, and conduction velocity → increased cardiac output and, in arrest, enhanced likelihood of ROSC; also increased myocardial oxygen demand and risk of arrhythmias
β2 effects: Vasodilation in certain vascular beds and bronchodilation; at low doses, β effects may predominate, leading to more inotropy/chronotropy and less vasoconstriction
During cardiac arrest: The primary beneficial effect is α1-mediated increase in aortic diastolic pressure and coronary perfusion pressure; β1 effects may contribute to ROSC but also to post-ROSC myocardial dysfunction and arrhythmias
In distributive shock: IV epinephrine combines vasoconstriction with inotropy and chronotropy, making it a potent agent for restoring perfusion in profound vasodilatory shock (e.g., anaphylactic or septic shock)

Pharmacokinetics – IV Epinephrine:

Onset: Immediate with IV bolus or infusion; peak effect occurs within minutes
Distribution: Rapid distribution to central and peripheral compartments, with an apparent Vd of ~0.2–0.5 L/kg
Metabolism: Rapid metabolism by COMT and MAO in liver, kidney, and other tissues to inactive metabolites (metanephrine, normetanephrine, VMA)
Elimination: Plasma half-life is only a few minutes; because of rapid metabolism, continuous infusion is required to maintain therapeutic effect in shock
Organ dysfunction: Hepatic and renal dysfunction have less impact on the extremely short acute half-life, but altered perfusion and receptor sensitivity in critical illness can significantly change clinical response

Indications

Cardiac arrest of any rhythm (VF/pVT, PEA, asystole) as per ACLS and PALS algorithms (IV/IO route)
Profound hypotension or shock (e.g., anaphylactic shock, septic shock with myocardial depression, cardiogenic shock with severe hypotension) when other vasopressors/inotropes are inadequate or unavailable, under intensivist guidance
Refractory anaphylaxis with persistent hypotension despite adequate IM epinephrine and fluid resuscitation (IV infusion)
Peri-arrest hypotension requiring temporizing vasopressor support while definitive therapy (e.g., volume resuscitation, definitive airway, definitive vasopressor infusion) is instituted
Occasionally as an inotrope/vasopressor during or after cardiac surgery and in certain forms of cardiogenic shock, per cardiac anesthesia/ICU protocols

Dosing & Administration

Available Forms:

Prefilled syringes: 0.1 mg/mL (1:10,000) epinephrine in 10 mL syringes for cardiac arrest (1 mg total per syringe)
Code cart syringes: Institution-specific preparations, typically 0.1 mg/mL for IV/IO use
Infusions: Prepared per institutional protocol from concentrated vials (often 1 mg/mL diluted to appropriate concentrations for continuous infusion)
Note: 1:10,000 (0.1 mg/mL) concentration is for IV/IO use; IM epinephrine uses 1:1,000 (1 mg/mL) concentration

Critical Concentration Warning: Always verify concentration before administration. IV/IO epinephrine uses 1:10,000 (0.1 mg/mL). IM epinephrine uses 1:1,000 (1 mg/mL). Never administer concentrated 1:1,000 epinephrine IV—this can cause catastrophic cardiovascular events including cardiac arrest.

Standard Dosing – IV Epinephrine (0.1 mg/mL, 1:10,000) – Always Follow ACLS/PALS and ICU Protocols:

Indication / Population	Dose / Concentration	Route & Frequency	Notes / Typical Maximum
Adult cardiac arrest (ACLS)	1 mg IV/IO (10 mL of 0.1 mg/mL, 1:10,000)	Every 3–5 minutes during CPR	Standard dose; high-dose epinephrine not recommended for routine use
Pediatric cardiac arrest (PALS)	0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL), max 1 mg per dose	Every 3–5 minutes during CPR	Use weight-based dosing or Broselow/length-based tools
Continuous IV infusion – shock (adult)	Start 0.02–0.05 mcg/kg/min; titrate 0.02–0.1 mcg/kg/min increments	Continuous infusion via central line preferred; titrate to MAP and perfusion goals	Common range 0.05–0.5 mcg/kg/min; higher doses may be used short term in refractory shock
Continuous IV infusion – anaphylactic shock (adult/pediatric, specialist use)	0.05–0.5 mcg/kg/min (or 1–4 mcg/min fixed-dose in some adult protocols)	Continuous infusion with close hemodynamic monitoring	Reserved for refractory anaphylaxis after IM epinephrine and fluids

Additional Dosing Notes:

IV epinephrine for cardiac arrest should be given as quickly as feasible once IV/IO access is established, without interrupting chest compressions
For non-arrest shock, epinephrine should be administered as a carefully titrated infusion, ideally via a central venous catheter; peripheral infusions may be used short term in emergent situations with vigilant monitoring of the limb
Push-dose ("bolus") epinephrine is typically prepared by diluting 1 mL of 0.1 mg/mL (0.1 mg) into 9 mL of saline to yield 10 mcg/mL; 0.5–2 mL (5–20 mcg) is then given as a slow IV push every 1–2 minutes as needed; this practice is protocol-dependent and should only be used in systems with clear guidelines and training
In anaphylactic shock, persistent hypotension after 2–3 appropriate IM doses and aggressive fluid resuscitation should prompt consideration of an epinephrine infusion with ICU-level monitoring
Avoid rapid IV boluses of concentrated epinephrine outside of cardiac arrest; such boluses are strongly associated with iatrogenic cardiac arrest and severe hypertension

Contraindications

Cardiac Arrest:

No absolute contraindications in cardiac arrest situations

Non-Arrest Use – Major Precautions:

Severe coronary artery disease or recent myocardial infarction: Epinephrine increases oxygen demand and can worsen ischemia; balance against need to restore perfusion
Tachyarrhythmias: (e.g., atrial fibrillation with RVR, VT)—epinephrine may exacerbate rate or trigger new arrhythmias; alternative vasopressors (e.g., norepinephrine, vasopressin) may be preferred in some shock states
Uncontrolled hypertension or aortic dissection: Profound vasoconstriction and increased shear stress may worsen outcomes; avoid or use minimal doses under expert direction
Concomitant MAO inhibitors or tricyclic antidepressants: May potentiate catecholamine effects; use lower doses and monitor closely
Peripheral administration at high doses or for prolonged periods: Increases risk of local ischemia and extravasation injury; monitor the limb closely and convert to central access as soon as feasible

Adverse Effects

Common (dose-related):

Tachycardia and palpitations
Hypertension (especially systolic) and widened pulse pressure
Tremor, anxiety, and headache
Hyperglycemia and transient lactic acidosis due to β-adrenergic stimulation

Serious:

Ventricular tachycardia/fibrillation or other malignant arrhythmias
Myocardial ischemia or infarction: Due to increased oxygen demand and coronary vasoconstriction
Severe hypertension: Risk of intracranial hemorrhage or acute aortic syndrome
Digital, mesenteric, or other regional ischemia: From intense vasoconstriction at high doses
Extravasation injuries: Local tissue necrosis (treat with phentolamine infiltration when recognized early)
Pulmonary edema: Especially with high doses or in patients with underlying cardiac dysfunction

Special Populations

Pediatrics: Use weight-based dosing (0.01 mg/kg IV/IO for cardiac arrest, max 1 mg per dose); continuous infusions for shock should be titrated carefully with specialist guidance
Pregnancy: Epinephrine is used for maternal cardiac arrest and refractory anaphylactic shock; maternal resuscitation takes priority; no dose adjustment needed
Older adults: Increased risk for arrhythmias, ischemia, and hypertension; use standard dosing in cardiac arrest; for infusions, start at lower end of range and titrate carefully
Renal/hepatic impairment: Extremely short plasma half-life means organ dysfunction has minimal impact on acute dosing, but altered receptor sensitivity and perfusion may affect response

Monitoring

Continuous ECG monitoring: For rate, rhythm, and ischemic changes
Invasive or frequent noninvasive blood pressure monitoring: Arterial line recommended for moderate- to high-dose infusions
Clinical markers of perfusion: Mental status, capillary refill, urine output, skin temperature, lactate trends, and organ function
Serum lactate and acid–base status: Particularly in high-dose or prolonged infusions, as epinephrine can increase lactate via β2-driven glycolysis
Inspection of IV/IO sites: For extravasation, especially when using peripheral lines

Clinical Pearls

Cardiac arrest outcomes: In cardiac arrest, epinephrine improves ROSC by increasing coronary perfusion pressure, but its effect on long-term neurologic outcome is less clear; follow current ACLS guidance while avoiding high-dose strategies that confer no proven benefit.

Distributive shock first-line: For distributive shock, norepinephrine is often first-line; epinephrine is useful when there is significant myocardial depression or when an additional inotrope is needed.

Push-dose bridging: When starting an epinephrine infusion in an unstable patient, a brief period of push-dose support can bridge until the infusion reaches steady state—but only with strict dosing protocols to avoid errors.

Multiple catecholamines caution: Be cautious when multiple catecholamines are running simultaneously (e.g., epinephrine plus high-dose norepinephrine and dobutamine); reassess frequently whether each agent still provides incremental benefit.

Documentation importance: Good documentation of dose, route, titration steps, and patient response is critical both for clinical handoffs and for code/debriefing review.

Dose-dependent effects: Lower infusion rates (0.02–0.1 mcg/kg/min) tend to emphasize β-effects (inotropy, bronchodilation), while higher rates (>0.1 mcg/kg/min) increasingly emphasize α-mediated vasoconstriction. This allows some dose-tailoring based on the clinical scenario.

Extravasation management: If extravasation occurs, infiltrate the affected area with phentolamine (5–10 mg in 10 mL saline) as soon as possible to prevent tissue necrosis. Monitor all peripheral infusion sites closely and convert to central access promptly.

Refractory anaphylaxis transition: In anaphylaxis, IM epinephrine is first-line, but if 2–3 doses plus fluids don't restore perfusion, don't delay transition to IV infusion with ICU monitoring. The patient needs more than you can deliver with intermittent IM dosing.

References

1. Dalal, R., Zhukovsky, S., & Dodd, A. (2024). Epinephrine. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482160/
2. American Heart Association. (2020). Part 9: Adult advanced life support. Circulation, 142(16_suppl_2), S366–S468. https://doi.org/10.1161/CIR.0000000000000916
3. Williams, C. A., Norton, V. G., & Brown, S. P. (2024). Use of epinephrine in cardiac arrest: Advances and future directions. Resuscitation Plus, 18, 100450. https://doi.org/10.1016/j.resplu.2023.100450
4. Pouessel, G., & colleagues. (2024). Management of refractory anaphylaxis. Allergy, 79(5), 1153–1167. https://doi.org/10.1111/all.15975
5. Boivin, Z., & colleagues. (2023). Epinephrine in cardiac arrest: Identifying a potential limit of benefit. Journal of the American Heart Association, 12(18), e028701. https://doi.org/10.1161/JAHA.123.028701