Adrenaline infusion guide for anaphylaxis (Table 14.15)
| Adrenaline infusion guide for anaphylaxis (Table 14.15) |
| 1 | PREPARATION Requires continuous physiological monitoring (ECG, SpO2, BP every 3 to 5 minutes). Give via infusion pump through a dedicated line, or piggybacked with anti-reflux valves on all other lines to prevent the adrenaline going back up into another fluid bag instead of into the patient. Beware infusions on the same side as a BP cuff; frequent BP measurement may interfere with the infusion. In first bag, use: adrenaline 1 mg in 100 mL sodium chloride 0.9% (10 micrograms/mL) IV, at 0.5 to 1 mL/kg/hour depending on severity (see below: Initiation and adjustment). See Box 14.13 for the emergency prehospital setting where an infusion pump is not available. If your hospital has a standardised adrenaline infusion protocol with which hospital staff are familiar, you should consider using it. [NB1] |
| 2 | INITIATION AND ADJUSTMENT Start at 0.5 to 1 mL/kg/hour (= approximately 30 to 100 mL/hour in adults) depending on reaction severity: moderate severity: adrenaline 1 mg in 100 mL sodium chloride 0.9% 0.5 mL/kg/hour (0.08 micrograms/kg/minute) severe (hypotensive or hypoxic): adrenaline 1 mg in 100 mL sodium chloride 0.9% 1 mL/kg/hour (0.17 micrograms/kg/minute). Titrate up or down according to response, aiming for lowest effective infusion rate. Allow for a short elimination half-life. Steady state is reached 5 to 10 minutes after a change in the infusion rate. Tachycardia, tremor and pallor, with a normal or raised blood pressure are signs of adrenaline toxicity. Reduce the infusion rate (if toxicity is severe, stop the infusion briefly before recommencing at a lower rate). The safe maximum rate of adrenaline infusion is unknown, but is probably less than 1 microgram/kg/minute (6 mL/kg/hour of a 1 mg in 100 mL solution). In the setting of anaphylaxis, high infusion rates are usually required only for a short period of time. |
| 3 | DE-ESCALATION AND CESSATION As the reaction resolves, an infusion that was previously therapeutic can quickly start to have toxic effects. Therefore when features of anaphylaxis improve, begin reducing the infusion, aiming for around half the starting rate if possible. One hour after the resolution of all symptoms and signs, wean the infusion over another 30 minutes and stop. Watch closely for reaction recurrence for the first 1 to 2 hours. |
| NB1: Note that the dosing regimen in this Table is expressed in micrograms per kg per minute, whereas many standard adult adrenaline infusion protocols, eg Box 14.4, are expressed in micrograms per minute. ECG = electrocardiograph; SpO2 = peripheral oxygen saturation; BP = blood pressure Adapted with permission from Brown SG. Anaphylaxis: clinical concepts and research priorities. Emergency Medicine Australasia 2006; 18(2):155-69. Copyright © 2006 Wiley-Blackwell Publishing Ltd. | |
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