Note: Please listen to the PDP update episode either before or immediately after listening to this one
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 (and even then, only sometimes)
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
Update:
This study compares push-dose phenylephrine to continuous infusion–no difference between the two (Anesthesia Analgesia 21012;115(6):1343)
First article in the ED demonstrates efficacy on blood pressure (The Journal of Emergency Medicine Volume 49, Issue 4, October 2015, Pages 488–494)
Here is a review article from the nursing literature
More on EMCrit
- Please listen to the PDP update episode either before or immediately after listening to this one
Additional Resources
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 383 – The Ultrasound Hierarchy of Needs in Cardiac Arrest with Mike Prats - September 6, 2024
- EMCrit RACC Lit Review – September 2024 - September 3, 2024
- EMCrit 382 – A Deep Dive on Vasopressin: Timing, Push Dose Vaso and the Vasopressin Load Test - August 23, 2024
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,… Read more »
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… Read more »
The algorithm would be sync cardioversion. I think increasing afterload is not your objective in this patient who has very little cardiac output.
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… Read more »
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… Read more »
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… Read more »
that subq infiltration stuff makes me a bit worried about the drug. what is the advantage over phenylephrine?, which is totally cool in infiltration.
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.
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… Read more »
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… Read more »
Great comment and great analogy!
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?
don’t see why not
What about push dose norepi?
Thanks!
probably would work, but I just need at least 1 study to be done
A bit late here, but were there studies looking at epi 5-20mcg pushes? If you are giving the norepi dose (5mcg every 5min equiv to 0.01mcg/kg/min), then is there anything to study?
yes, we know the drug effects would work fine, the ? is the safety in extrav. We know this dose of epi is perfectly safe (it is the conc. added to lidocaine); we need the same assurance with norepi.
Where I work:
Epi 1 mg/mL 1 euro
Norepi 5 mg/mL 20 euro
Phenyl 10 mg/mL 15 euro.
Maybe this helps you define your strategy in a playground without evidence of clear superiority of any agent.
Best,
Miguel
https://journals.lww.com/anesthesia-analgesia/Pages/ArticleViewer.aspx?year=2017&issue=07000&article=00034&type=Abstract
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.
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.
Interesting, not sure how USP has the ability/enforceability to alter hospital practice.
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.
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.
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.
The conversion above is wrong, With a 4 mg/4 ml amp of Levophed, 1 ml=1 mg=1000 mcg. If mixed in total solution of 10ml will yield 1000 mg/10 ml=100 mcg/ml NOT 10 mcg/ml. Please be careful with these potent pressors, especially with bolusing. That mistake can be very dangerous
you did not read the comment
my apologies for mis-reading the comment. Totally missed the re-dilution.
Still wrong. Will be 1000mcg/10ml or 100mcg/ml. I’d draw 1ml from this and dilute further down to 100mcg/10ml. Then you have your 10mcg/ml.
you DIDN’T READ THE ORIGINAL COMMENT
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
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?
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.
Hi Scott, it’s a bit late that I listened to this. But luckily I did finally…
One question though, phenylephrine is not available in my institution. So is it possible that I use norepinephrine as my pressor, in case i want the more pressor effect and less inotropic effect? How do you dose it if you are using norepinephrine?
Thank you.
see comments above yours. no reason not to want inotropy though, epi is pretty much a one-stop-shop.
Hi Scott, I love the podcasts. Here on my unit I’m trying to introduce 100mcg/ml peripheral ivi of phenyl on my unit- but am put off by the lack of literature supporting this concentration, due to risks of extravasation. Do you think it’s too high for continuous ivi?
Nigel are you talking push-dose (in which case all of the lit is 100 mcg/ml) or peripheral infusions in which case by all means go lower conc. if that is what people want. who cares at that point. though if you look at the SR in the updated section of peripheral vasopressors elsewhere on the blog, phenyl has an insanely good peripheral safety record
Scott,
Love your work. How about epi for the ROSC pt who is starting to drop their pressure and brady down before we can get a drip going? When would you pull the trigger, MAP<?, HR<? Also, how much rate effect do you think epi would have on the the hypotensive afib RVR pt who we want to try some dilt on instead of cardiovert? We don't carry phenylephrine yet…
Thanks,
Austin
Hi! I work with a physician that pushed 1mg epi to patients when they still had a pulse…it did not end well for the patient. Does anyone have resources that discuss the risks with this?
Thanks!
Hi Scott, I am GP working in a rural remote setting. We are currently working on pre-printed orders/protocols to help us more effectively and efficiently manage the occasional trauma/airway emergency. I am using your EMCrit Intubation Checklist as a starting point to create our own checklist, and I was wondering why phenylephrine does not feature in it. When would you use epinephrine VS phenylephrine as a push-dose pressor? I believe that I have recently heard you say epinephrine is the only one we really need, but I did not catch the reason why (other than simplicity and convenience). I would… Read more »
epi will work in all circumstances, increases cardiac output so drugs work faster, and is safer to mix then phenyl. no reason for task complexity–I just recommend epi now.
Hey Scott, this is one of my favorite posts on your site and probably the one I have forwarded the most. At my ED, we have only allowed Attending MDs to “mix” and administer push dose pressors mostly due to it being a “newer practice” and high risk drug. We would like to have nurses to start to push the actually drug with MDs ordering. Have you run across any issues with nurses giving this drug with proper training, of course? FYI, at my place nurses can push RSI meds and propofol so this is restriction to attending MDs is… Read more »
nurses seem much better suited than the docs
they are much more familiar with mixing meds and in general are more meticulous than the docs
one game-changer is we put the mixing instructions on the label
Great idea!!! Thank you Scott!
Hi Scott
Just wanted to share with you a couple of negative experiences with push dose adrenaline (10mcg/mL).
I’ve seen on two occasions transient worsening of hypotension and some bradycardia with a 1mL bolus through a CVC.
I wondered if anyone else had similar experiences with epi/adrenaline given as push dose.
Each occasion, a noradrenaline infusion has produced an improvement in the haemodynamic picture.
Any thoughts on this?
Dean
Hello! Great Podcast and instructions.
I have a question: What are your thougths on push dose pressors for diagnostic procedures like, for example, a MRI? I had this patient once who went to cervical MRI but blood pressure went down about 20 minutes after starting, since we can`t have infusions in the MRI room in our institution, the imaging had to wait until the patient didn’t need the vasopressor.
I am an acute care APP working in the MICU and relocating to a unit where APPs will be required to intubate.. your podcasts are priceless- they are clinically relevant and straight forward. I love them Thanks so much
The Institute of Safe Medication Practices strongly advocates AGAINST mixing drugs in a saline syringe….