Ever feel like you need epinephrine, and you need it now?
The "epi spritzer" goes by many names: low-dose epinephrine, low-dose bolus epinephrine, push-dose epi, "Peppinephrine," and "diet epi." All of them refer to epinephrine at 10 mcg/mL.
When to consider it
A patient with ROSC after CPR whose blood pressure is soft.
A near-arrest or hemodynamically unstable patient who needs a procedure such as endotracheal intubation.
Severe anaphylaxis where IM epinephrine is not enough and an epinephrine drip will take too long to start.
A severe asthmatic in whom you are trying everything to avoid intubation.
The Northwell guideline frames low-dose epinephrine as a temporary measure for hypotension or persistent bradycardia with a pulse in a patient with at-risk myocardium, while the underlying cause is addressed.
First, some math
1 mg = 1,000 micrograms (mcg), sometimes written as µg.
mg → mcg: multiply by 1,000 (move the decimal 3 places to the right).
mcg → mg: divide by 1,000 (move the decimal 3 places to the left).
Examples: 1 mg = 1,000 mcg; 0.5 mg = 500 mcg; 2 mg = 2,000 mcg.
Epinephrine in all its forms
| Traditional ratio | Concentration | Common use | Dose |
|---|---|---|---|
| 1:1,000 | 1 mg/mL | Anaphylaxis (IM) | 0.01 mg/kg |
| 1:10,000 | 0.1 mg/mL ("cardiac epi") | Cardiac arrest | 0.01 mg/kg (pediatric) |
| 1:100,000 | 10 mcg/mL ("epi spritzer") | Push-dose pressor | 1 mcg/kg |
The cardiac epinephrine syringe holds 10 mL, so 1 mg is the full 10 mL of 0.1 mg/mL.
How to make an epi spritzer
Both methods give the same concentration: 9 mL normal saline + 1 mL (0.1 mg) epinephrine = 10 mL of 10 mcg/mL (100 mcg total).
Method 1: Take a 10 mL normal saline flush, waste 1 mL, then draw 1 mL of cardiac epinephrine (0.1 mg/mL) into the same syringe.
Method 2: Take a 10 mL cardiac epinephrine syringe (0.1 mg/mL), waste 9 mL, then draw 9 mL of normal saline into the same syringe.
Label the new syringe ("epinephrine 10 mcg/mL") so there is no confusion.
Dosing
Weight-based dose: 1 mcg/kg.
Typical bolus: 0.5–2 mL (5–20 mcg) IV push every 1–5 minutes, titrated to hemodynamic effect.
Onset and duration: onset about 1 minute, duration about 10 minutes. The Northwell highlight sheet lists an immediate onset and duration under 5 minutes. Either way, expect to redose.
Weight-based dosing (Northwell low-dose epinephrine guideline)
| Patient weight | Dose of epinephrine 10 mcg/mL |
|---|---|
| < 2.5 kg | Draw up patient-specific dose |
| 2.5–5 kg | 0.5 mL (5 mcg) |
| 5.1–10 kg | 1 mL (10 mcg) |
| 10.1–15 kg | 1.5 mL (15 mcg) |
| > 15 kg | 2 mL (20 mcg) |
Safety
Monitor blood pressure, heart rate, and oxygen saturation.
Epinephrine can trigger arrhythmias, including ventricular fibrillation, in an irritable myocardium.
The concentrations are easy to confuse: always confirm the concentration and label the syringe.
Clinical pearls
Push-dose epi buys time; it does not fix the problem. Start a drip and treat the cause.
Have it ready before intubating a peri-arrest or hypotensive patient.
Product labels now state concentration in mg/mL rather than ratios, so communicate doses in mg or mcg, not ratios.
