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
Ephedrine
I don’t use this one much anymore, listen to the podcast to hear why.
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!
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 2-5 minutes (5-20 mcg)
No extravasation worries!
Mixing Video:
Phenylephrine
Phenyl as a bolus dose is just the best! It is clean, quick, and never causes trouble.
It is pure alpha, so no intrinsic inotropy, but increases in heart perfusion can improve cardiac output.
Onset-1 minute
Duration- 20 minutes
Mixing Instructions:
Take a 3 ml syringe and draw up 1 ml of phenylephrine from the vial (vial contains phenylephrine 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 2-5 minutes (50-200 mcg)
No extravasation worries!
Please send me any comments or questions
Mixing Video:
Podcast: Play in new window | Download (7.6MB)
Hi, my name is Scott Weingart. 
{ 16 comments… read them below or add one }
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.
Nice, I’ll incorporate this into my practice.
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
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
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?
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
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
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!!
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
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.
Scott
Again great talk!
Do you have metaraminol (aramine) in the US? I wonder what your experience if any is with this.
Zaf
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.
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