EMCrit Podcast 6 – Push-Dose Pressors

Finally a non-intubation topic!

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.

Click Here for printable sheet with mixing instructions

Epinephrine

Do not give cardiac arrest doses (1 mg) to patients with a pulse

Has alpha and beta-1/2 effects so it is an inopressor

Onset-1 minute

Duration-5-10 minutes

Mixing Instructions:

Take a 10 ml syringe with 9 ml of normal saline

Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (amp contains Epinephrine 100 mcg/ml)

Now you have 10 mls of Epinephrine 10 mcg/ml

Dose:

0.5-2 ml every 1-5 minutes (5-20  mcg)

No extravasation worries!

Mixing Video:

Phenylephrine

Phenyl as a bolus dose is clean, quick, and never causes trouble. But…

It is pure alpha, so no intrinsic inotropy; it may increase coronary perfusion which can improve cardiac output. I only use this in tachycardic patients.

Onset-1 minute

Duration- 5-10 minutes (usually 5)

Mixing Instructions:

Take a syringe and draw up 1 ml of phenylephrine from the vial (vial concentration must be 10 mg/ml)

Inject this into a 100 ml bag of NS

Now you have 100 mls of phenylephrine 100 mcg/ml

Draw up some into a syringe; each ml in the syringe is 100 mcg

Dose:

0.5-2 ml every 1-5 minutes (50-200 mcg)

No extravasation worries!

Mixing Video:

Ephedrine

I don’t use this one, listen to the podcast to hear why. I put it here solely for the anesthesiologists on the blog.

Onset-Near Instant

Duration-1 hour

Mixing Instructions:

Take a 10 ml syringe with 9 ml of normal saline

Into this syringe, draw up 1 ml of ephedrine from the vial (vial contains Ephedrine 50 mg/ml)

Now you have 10 mls of Ephedrine 5 mg/ml

Dose:

1-2 ml every 2-5 minutes (5-10 mg)

No extravasation worries!

Additional Video of a Real Patient

By Larry Mellick’s Crew

Update:

This study compares push-dose phenylephrine to continuous infusion–no difference between the two (Anesthesia Analgesia 21012;115(6):1343)

Now on to the Podcast…

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Comments

  1. reuben says:

    great pointers. I sometimes do something in between bolus epi and a proper drip – I take a milligram of crash cart epi, just because it’s the most available and already in a syringe, and put it into a 1 liter bag of NS. Attach to IV and titrate to effect using the knob. If the patient has a full or mostly-full bag of IVNS already hanging, I’ll just grab the crash cart epi and dump it in. Nothing could be faster.

    1 microgram/cc
    20 drops/cc
    therefore 2 drops per second = 6 mcg/min

    great for severe asthma and anaphylaxis, among your other pressor/inotrope needs.

  2. Nice, I’ll incorporate this into my practice.

  3. Would bolus doses of phenylephrine with some fluid resuscitation be appropriate in the following situation: patient with rapid atrial fib of unknown duration and hypotension? That is, in order to increase the BP to safely use meds to slow the rate. (Would the phenylephrine even be effective in raising the BP in this situation?) Or take your chances (of sending off a clot) with immediate cardioversion and forget the drugs?? OR…., is it possible that Beta blockers might actually raise the BP by slowing the rate and could be safely give as a singular medication?

    Thanks in advance for any input.

    JS

  4. Scott — i am a big fan of your web site and podcast and incorporate many of your ideas into my practice. i have a question in regards to the dose of push does epi . i know that you can make a quick epi drip by placing 1 ml of 1/10,000 into 100 ml bag of saline and running it in over 5-10 minutes.. your dose of 1 ml of 1/10,000 in 10 ml of ns seems too concentrated. i just want too make sure that this is the right dose.. keep doing what your doing

    Mike,

    Your mix will give between 10 and 20 mcg/min depending on whether you run it at 5 or 10 minutes duration

    the mix I advocate if given at the recommended 0.5-2 ml q 3-5 minutes will be giving 5-20 mcg every 3-5 minutes

    so you can see that if you ran in your drip, you would actually be giving a higher dose of epinephrine

    as to the concentration, the drip mix I advocate is 1:100000 which is the same as in your local anesthetic, so even though we inject it IV, it is unlikely to cause any problem if it extravasates into the sub-q

    please let me know if this makes sense

    Thanks for writing
    Scott

  5. Scott,

    How long is this bag of 100 cc of 100 mcg/mL phenylephrine I just made up good for? 1 hour? This shift? Can I hoard it in my office?

  6. Hi Scott,
    it may be because I’m from Scandinavia where the anesthetic culture is some different but why don’t you mention norepinephrine here, a clean alfa agonist with minimal side effects? We commonly use it both as bolus and drip?

    Regards and thx for a wonderful blog

  7. From a listener:

    Hi Scott,
    it’s 5-10 micrograms, repeat until effect. I just talked with my college at the ICU and he told me they also have phenylephrine but use it rarely as the primary vasopressor and in his experience the beta effect of NA was minimal. He added that he usually goes to code blue with an ampule of NA in his pocket, saving time while the nurses prepare for dobutamine drip…

    I must admit I haven’t used NA in my ER but that is not because of lack of interest but more that we are a new speciality here in Sweden. It’s a long story but it includes suspicious other specialties who still think we should leave vasopressors and airway management to the ICU team…. :-/

    Regards,
    David
    http://pricelesselectricalactivity.blogspot.com

  8. Dan Richardson says:

    HELP! I have tried this a few times with great success. Now my pharmacy committee states that there is a “lack of literature to support” and I am not able to get the Phenylepherine 10mg/ml vial… I would like any help you could give for references for use in A fib and hypotension. Help me try to advance in a frustrating system! I have residents who need to do this stuff!!

  9. Dan,

    I am baffled by the committee’s decision. Here is just one of scores of articles in the anesthesia literature:
    http://www.ncbi.nlm.nih.gov/pubmed/19032300
    Best thing to do may be to just have anyone from your anesthesia dept. send an email to the pharm folks. I am sure they are using this at least a 100 x a day in the ORs of your hospital.
    Let me know how this goes.

    Scott

  10. Scott –
    Excellent resource. The web address you listed for anesthesia reference appears to be available to Mount Sinai users only. It can be found on Pub Med #19032300.
    Our pharmacy folks are trying to shut down our use of this since we’re not using it the spinal anesth arena. Anyone find any literature or in house guidelines on using this in the ED/ICU setting.

    Thanks,

    Doug

    • thanks for picking up the bad link. I am sure your anesthesiologists can at least tell the pharmacy that they are doing it on ALL of their cases, not just their spinals. I have not seen any ED/ICU lit for push-dose, but phenylephrine drip is well reported and this is identical. Very frustrating.

  11. Scott

    Again great talk!

    Do you have metaraminol (aramine) in the US? I wonder what your experience if any is with this.

    Zaf

  12. Zaf,

    I don’t believe we have it here. Would love to hear your thoughts on it.
    s

    • Scott

      Quite a good, potent pressor that can be given peripherally. It is primarily an alpha agonist, and causes a reflex bradycardia. Fairly quick onset (within a minute) and I’ve used it mainly when vasodilation is the main problem pending a central line being placed. In England it is distributed as a 10mg in 1 ml vial, which you can dilute up to 20ml. The dose then is 0.5-1mg. Unfortunately it can be nasty if it leaks out into the subq tissue. In the appropriate setting I’ve found it very useful, and it has added to my armamentarium of peripherally administrable agents in the resuscitation room. I guess like choice of RSI drugs, knowing about a few allows you to tailor your patient’s treatment rather than be a one-trick pony. I’m not sure whether the FDA has approved this drug in the US but it might be worth looking into.

      Best wishes
      Zaf

      • that subq infiltration stuff makes me a bit worried about the drug. what is the advantage over phenylephrine?, which is totally cool in infiltration.

      • Anand Senthi says:

        yep agree, metaraminol is very useful and easy to use. No need to bother mixing up phenylephrine. Metaraminol comes ready to use in the vial. Pure peripheral squeeze.

  13. wrenn levenberg says:

    Hi Scott, I used push dose pressors with phenylephrine recently. Pt was in rapid afib, hypotensive with fever after being transferred from outside ED for further management of cellulitis and possibly needing OR for I&D. We started with 50mcg boluses which was effective and I bolused diltiazem 20mg (no drip), we repeatedly bolused her with phenylephrine using up to 200mcg. HR came down to <100, but BP remained low. We probably bolused 4-5x over 20min. I don't understand exactly the need to re-bolus if the duration of the drug is 20min, and also why I felt the need to give her 200mcg eventually when initially it seemed like 50mcg was sufficient. So, how long should this bolus thing be happening? When is it better to just start a drip? Ultimately, I determined she was septic and oliguric despite being on her 4th liter, so clearly her hypotension was due to another cause. But in the setting where the only cause of hypotension is rapid afib, how long should you be having to bolus?

    thanks very much. by the way, the RN i worked with was familiar with your lectures and this concept so he and I were both excited to use it. Wrenn

  14. mohammed ASIRI says:

    hi Scott
    thanks very much. I’ve been trying for years to convince my colleagues here in al Qassim,Saudi Arabia that IV pressor can be used outside OR for pre arrest while preparing drip ..(+ the reasons you mentioned: transient post intubation etc..). it takes time to prepare a drip ..on several occasions,I used Epinephrine (1:1000) because the prefilled cardiac epi is not available all the time.(I make it 1:10000 by diluting 1 ml in 9 ml of NS)…then again I take that and I add it to another 10 cc syringe after filling it up with 10 cc NS and discarding 1cc..I found it really helpful and people trust me here, they dont ask why ..I remember my influence from old edition of Civetta’s Critical Care 3rd edn page 341a chapter by Robert Schlchtig ..”During profound hypotension pressors are absolutely essential for initial management..you could wait for intravascular expansion alone to raise the patient’s BP ,just as you could also routinely ignore stop signs….” that was in 1997 edition and ever since I believed that there is a gap we have to bridge in these desperate moments!!..point is.. you need to fill up the coronories no matter what ..and according to him think of other benign ways later one before you being hit by an”automobile accident” to use the analogy of Schlichtig… thanks again ..BIG FAN!!

  15. Kevin Klassen says:

    Scott,

    I’m a 4th year med student who just finished a month of anesthesia. The pharmacy pre-prepares phenylephrine and ephedrine push-dose syringes for the staff at this hospital with a computer-printed label on every syringe. Is this something the pharmacy could do in the ED as well?

  16. What about push dose norepi?

    Thanks!

  17. Scott-
    Thanks for this great lecture which has helped on several occasions.

    How long are the “sticks” good for? How long can I keep the syringe (or bag in the neo case) around? The epi is pretty common, but once I mix up the neo, can I keep that 100cc mixture in my bag for…a day/week/month?

    Thank you.

    • 1 hour if not compounded in a sterile hood that is certifed for aseptic technique

      • Cody, you may as well shut down the anesthesia services of every hospital in the world with that cut-off. Most hospitals would use somewhere between 8-12 hours for non-pharmacy mixed medications. Do you have any references? Much thanks for commenting.

        • Dr. Pill says:

          EMCRIT, 1 hour is the limit for IV products that are compounded outside of the pharmacy per USP 797 guidelines. Many hospitals are currently non-compliant with 797, especially in the OR setting.

  18. Easier epi mixing:
    Take a 1mL vial of 1:1000 epi (a la anaphylaxis) and add it to a 100mL bag of NS. This will give you 1:100,000 epi. The method is then identical to phenylepherine – 1 amp/bottle mixed in a 100mL bag.

    • absolutely and others have written in with this as well. Thr problem is that I feel the epi is the better method and the phenyl is an inferior one. I want one syringe hanging around, not a bag. Keep the cardiac epi vial and when you finish a syringe, make a new syringe. I don’t want bags of these drugs hanging around.

  19. Matthias Barden says:

    Hi Scott,
    I was just curious about something I saw on phenylephrine’s labeling. It mentioned IM/SubQ dosing for hypotension. I haven’t heard of that before, and I was imagining if that might be an option for push dose pressor in a crashing patient with no IV access?

    • Its approval for SubQ dosing is what makes me feel confident of its safety–would not use this as a rescue for a shocked pt. Place an IO.

  20. HASSAN ALMAATEEQ says:

    that’s great.. what about levophed push doses (4mg/4ml)
    take 1ml of levophed with 9ml of NS.. then take 1ml of the new dilution to 9ml of NS .. you will have 10mcg/ml .. just like epinephrine..
    in my hospital , we don’t have the 1:10,000 epinephrine ready..
    what do u think ?

    • I think I have been waiting for someone to do safety in extrav studies forever. If even a single study went into the literature, I would start using this immediately.

  21. UK PARAMEDIC says:

    I know this is a bit of an old topic, however the use of bolus IV adrenaline has just been introduced into our practice in post-rosc care – which is good!! However the dose we are advised to give is 100mcg every 2 mins. I wondered what your opinion was on this dosage

    • Think it is about 10x too high. It will only take a few pts to demonstrate this thanfully

      • UK PARAMEDIC says:

        Thanks for your reply Scott. Right well I had better do something about it! Off the top of your head are you aware of any specific research on the dose or adverse incidents with our suggested regime?

        • William Selde says:

          The AHA guidelines for cardiogenic shock list the dose for epi at 0.1-0.5mcg/kg/min so 100mcg/2 min would be the upper limit for a 100 kg patient. That being said, its always prudent to titrate to effect.

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