Push Dose Pressors
Dr. Andrew Cox
edited by Ilyas Taraki
The median time to infusion initiation after physician order for a vasopressor is approximately 8 minutes on average. Oftentimes, these crashing patients can’t afford 8 minutes without support. Thus, it falls on the emergency medicine physician to bridge this gap with either fluids or push dose pressors. Push dose pressors are often concocted at bedside, using the ACLS pre-loaded doses of epinephrine and diluting it in 0.9% normal saline. My knowledge bomb draws light on the utility, presumed benefit, and accuracy of push dose pressor use in the emergency department.
Cole, J. B., Knack, S. K., Karl, E. R., Horton, G. B., Satpathy, R., & Driver, B. E. (2019). Human Errors and Adverse Hemodynamic Events Related to “Push Dose Pressors” in the Emergency Department. Journal of Medical Toxicology, 15(4), 276-286.
This was a retrospective, structured chart and video review performed at Hennepin Healthcare in Minneapolis, MN. Data was gathered from December 2010 to November 2017 and consisted of ceiling-mounted video camera footage from the 4 resuscitation bays and evaluation of when push dose pressors (defined as any dose of phenylephrine or <100mcg of epinephrine) were used. The study measured 2 outcomes: 1.) The prevalence of adverse hemodynamic events up to 10 minutes after giving the push dose pressor, and 2) the instances of human error.
The prevalence of adverse hemodynamic events were measured by 4 parameters:
extreme tachycardia (HR>140)
new bradycardia (HR<60)
Instances of human error were further divided into 2 categories:
whether the wrong dose was given
whether an error was made in the physician documentation.
The study found that 98 patients (39%) who received push dose pressors experienced an adverse hemodynamic event, and 47 patients (19%) had at least 1 element of human error in the case. Both types of errors were more common when using epinephrine as opposed to phenylephrine.
I believe push dose pressors are well within the scope of practice for emergency department physicians and have the ability to provide a necessary bridge between a crashing patient and the initiation of a pressor drip. However, one must ask themself if the hypotension could be adequately treated with fluid resuscitation alone, and they must have the comfortability and knowledge in how to appropriately mix medications to procure the correct concentration and desired dose.
Pearls and Pitfalls:
Ask yourself, could I treat this hypotension with fluid resuscitation alone?
Know what your particular hospital carries (phenyl sticks vs. epinephrine)
Be comfortable mixing medications and doing mental math at locations without pharmacists
Label your syringe after you have made a concoction
Closed loop communication with staff at all times (nursing, pharmacy, techs)
Complete your notes as soon after these cases as possible so you remember the doses given etc.
Scott Weingart. EMCrit Podcast 205 – Push-Dose Pressors Update. EMCrit Blog. Published on August 7, 2017. Accessed on June 17th 2020. Available at [https://emcrit.org/emcrit/push-dose-pressor-update/ ]