Push dose pressors are a great option to us in the ED. While the majority of us may be familiar with what these are and how to use them, we still could all use a refresher on their utility. Additionally, we now have 12 new faces in the department whom this may be a new concept for.
It is first important to note that EM Crit does the best job talking about this, and this is largely a review of his blog post (EM Crit Podcast 6 - Push Dose Pressors). That is because although push dose pressors have been used in the anesthesia world for decades, they are not as commonplace in the ED. Additionally, a literature search did not turn up much evidence. As such, much of their use and utility is from expert opinion and experience.
As the name implies, push dose pressors are administering a pressor in a bolus or "push dose" IV form. The two common drugs used in this scenario are epinephrine (alpha and beta) and phenylephrine (pure alpha).
Why does it matter?
These matter because they can be life saving interventions, in the right circumstances. A classic example is the hypotensive patient that needs to be intubated. Sure they may be fine with etomidate, but intubating an unstable patient may be nerve wracking and could potentially precipitate them coding. Or how about the unstable atrial fibrillation patient with RVR that does not convert after an initial shock? These are just two examples of why it matters to be able to temporarily raise the BP until you have the time or opportunity to stabilize the patient.
What do I need to know?
Our pharmacy helps us out and mixes dwindle epi and stocks it in the Pyxis. That's great, until you are in the real world and do not have this luxury. In that case, you need to know how to mix it.
First for epinephrine
- Get a 10 mL NS flush
- Remove 1 mL
- Take a vial of "code dose" or 1:10,000 concentration of epinephrine. This has 1 mg in the 10 mL vial. This gives you 0.1 mg or 100 micrograms/mL
- Draw up 1 mL (100 micrograms) into the NS flush
- This gives you 10 mL of epinephrine with a final concentration of 10 mcg/mL
- Get a 10 mg/mL vial of phenylephrine
- Draw into a syringe
- Inject into a bag of 100 mL of NS and shake
- This gives you 100 mL of phenylephrine at a concentration of 100 mcg/mL
What do I need to do?
- 1-2 mL or 10-20 micrograms every 2-5 minutes
- This would be equivalent to 2-10 mcg/min, which is a typical dosing order if you order an infusion in EPIC
- Duration of action is 5-10 minutes
- 0.5-2 mL or 50-200 mcg every 2-5 minutes
- This would be equivalent to 10-100 mcg/mL. A atypical dosing order would be 50-150 mcg/min
- Duration of action 10-20 minutes
Hope you enjoyed the primer on push dose pressors. Keep them in the back of your mind, but remember to always use with caution and in the appropriate clinical scenario.
Disclaimer: This is for informational purposes only and is not intended to provide recommendations or provide clinical guidelines.
Submitted by Dr. Michael Craddick, PGY-2