Push Dose Vasopressors
- The team gets a call that there is a 75 year old male that triggered a sepsis alert in route with EMS and is currently desaturating on 15 L of oxygen with decision made to intubate this patient
- Prior to intubation, the patient hasn’t responded to a NS bolus infusion these are the patient’s vitals:
- Knowing that pre-intubation hypotension has been associated with peri-intubation cardiac arrest, which agent do you order? If it is not commercially available, how do you make it?
|Phenylephrine (PE)||Epinephrine (EPI)|
|Properties||A1 ++++ ↑ BP B1 ± ↔HR B2 ±||A1 +++ ↑ BP B1 +++++ ↑ HR B2 +++++|
|Dose||100-200 mcg PRN Q 1-5 minute||10- 20 mcg PRN Q 1-5 minute|
|Formulation||Premixed Syringe- 1000 mcg/10 ml||Not commercially available|
|PK/PD||Onset: 1 minute Duration: ~10-20 minutes||Onset: 1 minute Duration: ~5-10 minutes|
|Adverse Effects||Reflex bradycardia Hypertension||Tachycardia Hypertension|
|Precautions||Bradycardia, heart block, heart failure, angina, acute MI||Tachycardia|
|Compatibility||Compatible with NS, LR, D5||Compatible with NS, LR, D5|
|Location in GHS||CPR, Trauma, Zone 2+3 Pyxis||1 mg/ml: CPR, Trauma, Zone 2+3 Pyxis|
|Comments||Administer through a large bore peripheral IV; Low extravasation risk||Administer through a large bore peripheral IV; Low extravasation risk|
|Making Epinephrine and Phenylephrine the “EASY WAY” Supplies: 10 ml of NS, Insulin syringe, epinephrine or phenylephrine vial, tape, pen Instructions: Take an insulin syringe and draw up 0.1 ml of epinephrine 1 mg/ml or phenylephrine 10 mg/ml, dilute in 10 ml of NS, label epinephrine 10 mcg/ml (100 mcg total) or phenylephrine 100 mcg/ml (1000 mcg total)|
|Making Epinephrine and Phenylephrine the Alternative Way Epinephrine Draw up 9 mL of normal saline into a 10 mL syringe (DO NOT use 10ml IV line “flush” syringes) Into this syringe, draw up 1 mL of EPINEPHphrine 0.1 mg/mL (1 mg/10ml) from a cardiac syringe Label syringe epinephrine 10 mcg/ml Phenylephrine o Draw up 1 mL of phenylephrine from a 10 mg/mL vial into a 3 mL syringe o Inject this into a 100 mL bag of normal saline. Label bag; safely discard when finished o Draw up 10 mL into a 10 mL syringe o Label syringe phenylephrine 100 mcg/ml|
Overview of Evidence
|Author, year||Design/ sample size||Intervention & Comparison||Outcome|
|Rotando, 2019||Observational ED/ICU N=146||PE 100 mcg/ mL or Ephedrine 50 mg/10 mL||Most common indication = peri-intubation hypotension Both agents associated with: ↑ SBP by 26 mmHg ↑ SBP by 26 mmHg ↓ HR by 6 beats per minute|
|Schwartz, 2016||Observational ED N=76||PE 100 mcg/ mL (pre-filled syringe)||46.5% patients were initiated on vasopressor drip ≤ 30 minutes; mean MAP ↑ from 56.5 to 79.3 mmHg most common dose 100 mcg most common indication = peri-intubation hypotension|
|Panchal, 2015||Observational ED N=119||PE 100 mcg/1 mL||PE given during the peri-intubation period: ↑ SBP by 20 mmHg, ↑ DBP by 10 mmHg, HR unchanged|
|Doherty, 2012||RCT OR N=60||PE IV push 120 mcg (pre-filled syringe) Vs PE infusion @ 120 mcg/min||The infusion used more drug ( 1740 v 964 mcg) Push dose pressor had favorable impact of MAP compared to infusion|
- Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved March 18, 2019, from http://www.micromedexsolutions.com/
- Scott Weingart. EMCrit Podcast 205 – Push-Dose Pressors Update. EMCrit Blog. Published on August 7, 2017. Accessed on March 19th 2019. Available at [https://emcrit.org/emcrit/push-dose-pressor-update/ ]
- Holden D. Ann Emerg Med. 2018 Jan;71(1):83-92.
- Panchal AR. J Emerg Med. 2015 Oct;49(4):488-94.
- Rotando A. Am J Emerg Med. 2019 Mar;37(3):494-498.
- Doherty A. Anesth Analg. 2012 Dec;115(6):1343-50.
- Schwartz MB. Am J Emerg Med. 2016 Dec;34(12):2419-2422