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Push Dose Pressors: Your Quick & Dirty Guide

In the resuscitation bay, there are a handful life-saving tools we regularly keep within an arm’s reach during each resuscitation – tools for some of those critical moments that could prevent your crashing patient from coding if you quickly employ them when needed. Some of my all-time favorites are obviously the ultrasound machine, Bi-Pap, the Glidescope, etc., etc...… But another favorite of mine is a tool that works within seconds and is a great temporizing measure in patients with dangerously low perfusion when you need an immediate increase in blood pressure, STAT.

Enter: Push-dose pressors.

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 Push-Dose Pressors

Bolus dose pressors and inotropes have been used by the anesthesiologists for decades, but they have not penetrated into standard emergency medicine practice. I don’t know why. They are the perfect solution to short-lived hypotension, e.g. post-intubation or during sedation. They also can act as a bridge to drip pressors while they are being mixed or while a central line is being placed.

Articles of Interest

Push Dose Pressor app provides bolus preparation instructions

The developers at ITDCS have created an app, Push Dose Pressors, to help physicians titrate pressors based on weight that can subsequently be given as boluses to critically ill children and adults. Providers can choose between the following pressors – epinephrine, ephedrine, metaraminol, and phenylephrine – at either a fixed concentration or a fixed volume.

Push Dose Pressors – The Full Safety Dance

Although I’ve been using push dose pressors for years now, I still researched the topic awhile ago. Frankly, there wasn’t much out there – and there still isn’t. Why? Because it’s not standard of care. But I suspect it will be once there are RCTs and more research and we all know that takes time. Meanwhile, this is a practice that is happening in our Emergency Departments and as ED nurses, we definitely should know about them.

Steps for drawing up epinephrine for push dose epinephrine and epinephrine infusion

Inject 1 mg of epinephrine 1:10,000 (one amp of crash cart epi) into a 1L bag of normal saline. Draw up 10mL from the 1L bag in a 10mL syringe (The concentration of epinephrine in the syringe is now 1 mcg/mL). Push Dose: 10 mL every 2-5 minutes (10 mcg). note that the onset = 1 minute and duration = 5-10 minutes. Dose of epinephrine given via infusion: 1mL/min (1 mcg/min) and titrate to a maximum of 20mL/min.

Back to Basics: Push Dose Vasopressors

You are responding to a cardiac arrest and the patient has achieved return of spontaneous circulation however his blood pressure drops to 68/40 mmHg. You would like to use push dose epinephrine. How is this prepared?

Comparison of push-dose phenylephrine and epinephrine in the emergency department

PDP-E provided a greater increase in SBP compared to PDP-PE. However, dosing errors occurred more frequently in those receiving PDP-E. Larger head-to-head studies are necessary to further evaluate the efficacy and safety of PDP-E and PDP-PE.

Do Push Dose Pressors Have A Role In Prehospital Care?

The most common cited indication for the PDPs is as a bridge to vasopressor initiation.

Pearls and Pitfalls with Push-Dose Pressors

Push-dose pressors may also be used during bouts of hypotension in the peri-intubation patient, or the patient undergoing procedural sedation who experiences hypotension. The use and preparation of these medications carry inherent risks when used in the ED, such as multiple manipulations of dilution, dose calculations, and incremental push-dose administration, which are all areas where errors may occur and may be potentially fatal. The ED is an environment ripe for potential medication errors due to reliance on verbal orders and bypassing certain medication safety checks, including verification of medication orders by a pharmacist prior to medication administration. When using push-dose pressors, explicit communication is key in order to administer the vasopressor safely, avoid medication errors, and optimize pharmacotherapy.

Podcast 801: Push Dose Vasopressors

There are two common options for push-dose vasopressor: phenylephrine and epinephrine. Both have been studied in the setting of the OR, but are lacking data in emergency room utilization. A recent retrospective study at one hospital compared the two options for effectiveness and safety. The data showed phenylephrine raised systolic pressure an average 26 points while epinephrine raised the systolic pressure higher, an average of 33 points. Additionally, the same study showed dosing errors were more common in epinephrine. The error rates were 13% and 2% when using premixed syringes of epinephrine and phenylephrine respectively. However, overall no increase in adverse outcomes were reported between the two drugs in this study.

Push dose epinephrine alternatives

Bottom Line: To reverse acute transient hypotension you may consider: -A bolus of phenylephrine 50-200 ug (0.5-2 mL from neo-stick) -A bolus of norepinephrine 3-7 ug -Briefly increasing your norepinephrine drip (if you have one) to something around 0.1 ug/kg/min in a typical weight patient

Push Dose Phenylephrine

Draw 1 ml (10mg) from a phenylephrine 10 mg/ ml vial. Inject into 100 cc bag of saline. Shake thoroughly, then draw 10cc from the bag into an empty syringe. Label syringe. Now each 1 ml contains 100 mcg of phenylephrine.

Push-dose pressors for immediate blood pressure control

Push-dose pressors have been used for decades in the operating room. The translation of this technique to the emergency department or intensive care unit is logical and useful. If only one push-dose pressor is to be used, epinephrine should be the choice.

Push-Dose Pressors Update

The idea was not new, anesthesiologists and resus docs have been using bolus-dose vasopressors for decades.

Push-Dose Vasopressors: An Update for 2019

Due to their rapid onset and short duration of action, push-dose epinephrine and phenylephrine can be considered for patients with spontaneous circulation requiring rapid normalization of hemodynamic parameters.

RX Pad: When push comes to shove

Some of the proposed benefits of PDP is the ability to mix and administer them faster than the time it takes to prepare or receive an infusion from pharmacy, prime tubing, find a pump and program it. One of the most frustrating things is to get ROSC on a cardiac arrest patient, only to have them code shortly thereafter while the team is trying to get a vasopressor infusion started.

The Dirty Epi Drip: IV Epinephrine When You Need It

Be safe. Never push IV epinephrine 1:1,000 or 1:10,000 to a patient with a pulse. Use the “Dirty Epi Drip” trick as a temporizing measure until a pharmacy-made drip is available.

The Safety and Efficacy of Push Dose Vasopressors in Critically Ill Adults

Although conclusions on mortality and clinical outcomes cannot be definitively made, this retrospective study demonstrates the safe and efficacious use of PDP in the acute hypotension period with no severe adverse effects.