Emergency adrenaline infusion without an infusion pump for life-threatening anaphylaxis-induced hypotension in an adult or adolescent (Box 14.13)

Emergency adrenaline infusion without an infusion pump for life-threatening anaphylaxis-induced hypotension in an adult or adolescent (Box 14.13)

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If an adult or adolescent with anaphylactic shock remains hypotensive despite IM adrenaline and fluid resuscitation (20 mL/kg normal saline run through as rapidly as possible under pressure), then an intravenous infusion of adrenaline, even without an infusion pump, is warranted [NB1] [NB2]. This is a temporary measure until emergency medical services arrive or the patient can be moved to a critical care area. Use it only for severe cases where death is considered likely without intervention. In this situation, through another peripheral intravenous line, use: adrenaline 1 mg in 100 mL sodium chloride 0.9% IV, at approximately 100 mL/hour, which is one drop every 2 seconds for most standard drip sets [NB3]. If you only have a 500 mL or 1000 mL bag of infusion fluid [NB2], use: adrenaline 1 mg in 500 mL sodium chloride 0.9% IV, at approximately 500 mL/ hour, which is 2 drops per second for most standard drip sets OR adrenaline 1 mg in 1000 mL sodium chloride 0.9% IV, at approximately 1000 mL/hour, which is 5 drops per second for most standard drip sets. Titrate carefully, monitoring systolic blood pressure every few minutes using the 'palpation' method, see Assessment of blood pressure in anaphylaxis. Reduce the rate immediately if signs of adrenaline toxicity (tachycardia, tremor and pallor in association with a normal or raised blood pressure) develop. If toxicity is severe, stop the infusion briefly before recommencing at a lower rate. See Table 14.15 for further advice regarding adjustment, de-escalation and cessation of the adrenaline infusion.

NB1: Children with severe/persistent anaphylaxis usually have a bronchospastic reaction rather than a hypotensive one. Absorption from the intramuscular site will be good; therefore, use a second intramuscular dose rather than an infusion (see Children with life-threatening anaphylaxis). NB2: Adrenaline is compatible with most standard infusion solutions. Normal saline (sodium chloride 0.9%) is preferred in anaphylaxis, but if supplies are being used for simultaneous fluid resuscitation, use glucose 5% or any other standard infusion fluid for the adrenaline infusion. NB3: For most standard drip sets 1 mL = 20 drops. Therefore for a 100 mL bag, you will be giving 20 x 100 = 2000 drops per hour, or approximately 30 drops per minute, ie one drop every 2 seconds. For a 500 mL bag, it will be 5 times this rate (150 drops per minute or approximately 2 drops every second) and for a 1000 mL bag, it will be 300 drops per minute or 5 drops per second. Table (adapted with permission from Brown SG. Anaphylaxis: clinical concepts and research priorities. Emergency Medicine Australasia 2006; 18(2):155-69. © 2006 Wiley-Blackwell Publishing Ltd.)