June  20, 2025

Welcome again to UH EMSI’s Pharmacy Phriday CE offering. In this installment, we focus on push dose epinephrine (PDE). 

The June 2025 continuing education topic for the UH system covers critical care and sepsis; last week’s Pharmacy Phriday reviewed using normal saline (NS). When considering septic shock, NS is one of the first agents used to attempt to maintain a perfusing blood pressure. If boluses of NS are unsuccessful or if the patient is already overloaded with fluids, the next treatment to consider is the use of PDE, sometimes referred to as an “Epi Spritzer.”  

Epinephrine is a catecholamine that is found naturally in the body that affects the sympathetic nervous system. It is an adrenergic (sympathomimetic) agent and cardiac stimulant that acts on both alpha and beta receptor sites.  

Epinephrine’s alpha effects cause vasoconstriction that improves perfusion pressure to the brain and heart. Its effect on beta receptors includes those of the heart, vascular, and other smooth muscles. Stimulation of the beta1-adrenergic receptors in the heart results in a positive inotropic effect (increasing contractility), a positive chronotropic effect (increasing the heart rate), and a positive dromotropic effect (increasing the rate of conduction through the AV node). Due to both the alpha and beta actions, PDE is indicated for septic, cardiogenic, and neurogenic shock, hypotension in post-resuscitation care, and bradycardia. 

Epinephrine is provided in our UH drug boxes in various concentrations that include: 

• The 1 mg/ml concentration (old ratio 1:1000), sometimes referred to as IM epinephrine 

• The 0.1 mg/ml concentration (old ratio 1:10,000), sometimes called cardiac epinephrine 

• Racemic epinephrine, 0.5 ml 2.25% solution used for aerosol treatments 

Be sure you have the correct concentration and dose for the proper treatment before administration!  

For the administration of PDE, the provider must prepare the proper concentration. There are many suggested ways to mix this medication, but the preferred method of the UH system and its medical directors is described in the protocols (see the illustration below). 

To prepare this concentration, the provider can use the “pull one, push one, pull one, push one” mnemonic. This will assist the provider to remember the following steps: 

1. Pull One - Draw up 1 mg of epinephrine 1 mg/ml (1000 mcg/ml). Be sure to use a filter needle if drawing from an ampule and discard the needle before injecting it into the 100 ml bag.  

2. Push One - Add the 1 mg of epinephrine to a 100 ml bag of D5W or NS and mix. This results in a 10 mcg/ml concentration. Be sure to label the bag appropriately! 

3. Pull One - Draw up from the bag to administer the new concentration.  

4. Push One – Administer 1 ml or 10 mcg as a slow push, titrated to the desired effect of maintaining a MAP >65, a systolic pressure >90, or the presence of peripheral pulses. The provider may give up 50 mcg or 5 ml for a single dose if needed to meet the desired effect. 

As always, monitor the patient and their blood pressure. The need to repeat the PDE dosing is very likely. As soon as the provider notes a drop in blood pressure, another dose should be administered. If continued administration is needed, the provider can choose to convert the PDE to a drip. This can be accomplished by spiking the mixed bag with a 10 gtt set (1 gtt will equal 1 mcg) and titrating the drip rate to the desired effect.  

The use of PDE in the pediatric patient is within the protocol but requires online medical direction approval. The listed dosage is 1 mcg/kg every 2-5 minutes with a max dose of 10 mcg.

As always, stay safe!

Sincerely, 

The UH EMS-I Team 

University Hospitals