Today, an update on Push-Dose Pressors. I coined the name Push-Dose Pressors (PDPs) way back on episode 6. The idea was not new, anesthesiologists and resus docs have been using bolus-dose vasopressors for decades. I just thought the name was dumb, these are not boluses in the way I have always thought of them (a brief iv drip). I also thought it was crazy that the concept had not really penetrated very far into emergency medicine and the ICU–at least in the States. My prehospital doc friends told me it was common in their world. Since the podcast, I have received 100s of emails describing the use of PDPs to lifesaving effect (or at least code-preventing), but there has been scant published literature on this technique in EM. Recently that has all changed.
Can We Wait for the Drip?
Resus-Ready EDs should be able to get a vasopressor drip up within 8 minutes (completely made-up number, just like most hospital certification standards)
Dead Space in the Lines
What should you do when you can't wait that long?
How do you treat critically low perfusion to the heart & brain?
Push-Dose Pressors Fill the Gap
Especially in the Peri-Intubation, when patients have an annoying habit of popping into cardiac arrest
ED Pharmacists Discussion of Medication Safety for Push-Dose Pressors
While there seems to be a slightly negative bias against docs' capability to mix drugs and a pro-pharmD bias (understandable), the messages from this article as a whole were fantastic. Here are some alterations/things to be aware of that I discuss in the podcast:
- The Prohibition against Pre-Filled Saline Syringes
- The Phenylephrine Chart
An Editorial on the Above Article
Why EPI has won my Heart
Sorry Phenyl you were but a brief fling
Push-Dose Epi Labels
Inspired by the Danny the Medic
Cardiac Arrest EPI Syringe
0.5 mls of the cardiac arrest epi is an ok stopgap
Dirty Epi Drip
I do not recommend the dirty epi drip. Please, please understand how this makes our specialty look
For the love of all this is Resus, Label the frackin bag!
This is not the time to have something going on in the background that you are paying no attention to
Push-Dose Norepi if you Just Never Want to Deal with Mixing
Check your premixed concentration: If you have the 4mg in 250 ml (16 mcg/ml) you can give 0.5 to 1 ml per minute
Pick One Way to Go in your ED
Otherwise errors are more likely
ED Pharmacists in General
Love having ED PharmDs as part of the team! Are there downsides?
Premixed Push-Dose Epi
Other Lit Mentioned
- The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting. The American Journal of Emergency Medicine Volume 34, Issue 12, December 2016, Pages 2419–2422
- 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)
- Acquisto NM et al. Medication Errors with Push Dose Pressors in the Emergency Department and Intensive Care Units (AJEM In Press)
- Push Dose in CCT
- Some of my favorite EM PharmDs have responded to the Acquisto letter to the editor
- Push-Dose NorEpi
- Braude's group published safety data on phenylephrine1
Now on to the Podcast…
- EMCrit 290 – Decompensated Hypothyroidism and Myxedema with Dr. Arti Bhan - January 23, 2021
- EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver - January 12, 2021
- EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock? - December 29, 2020