Bolus (Push Dose) Pressors: Good Idea or a bit Much? Robert Katzer MD MBA FACEP FAEMS Associate Professor, Emergency Medicine University of California, Irvine
Pressors: Which Ones Are Out There, What Do They Do? Norepinephrine Phenylephrine Epinephrine Dopamine Dobutamine Vasopressin 2 Department Name Month X, 201X Image: www.foodandwine.com
The Different Categories of Shock Obstructive Shock: Extra-cardiac mechanical causes Tension pneumothorax Pericardial tamponade Pulmonary embolus Pulmonary hypertension Hypovolemic: Insufficient intravascular volume Hemorrhagic Extreme dehydration Metabolic derangement 3 Department Name Month X, 201X
The Different Categories of Shock -CONTD Cardiogenic: Results from inability of heart to adequately pump blood forward Valvular dysfunction Arrhythmia Cardiomyopathy Distributive: Results from excessive vasodilation Sepsis Systemic Inflammatory Response Syndrome (SIRS) Anaphylaxis Neurogenic Endocrine 4 Department Name Month X, 201X
Shock: There s an App Pressor For That. Or Is There? *** Agent Alpha-1 Beta-1 Beta-2 Dopamine Comments Phenylephrine +++ Epinephrine +++ +++ ++ Norepinephrine +++ ++ Dopamine 0à** +à++ ++ Dose dependent Dobutamine +++ ++ Vasodilator, may result in increased, no change, or decreased BP How these work: change in CO + change in SVR = Change in perfusion *** This is not a comprehensive list of all pressors and inotropes 5 Department Name Month X, 201X
Bolus Dose Pressors Long history in anesthesia during surgery Phenylephrine and ephedrine most common Spinal anesthesia, often during C-section, provided a common indication 6 Department Name Month X, 201X Image: wikipedia
Push Dose Pressors, Brought to You By FOAMed 7 Department Name Month X, 201X
Push Dose Pressors, Brought to You By FOAMed More recent history of bolus dose pressors introduction into the emergency department. Recently introduced into the emergency medicine world When would these be used in ED?? Post intubation hypotension As a temporary bridge while pressor drips are mixed, central lines placed During procedural sedation 8 Department Name Month X, 201X
Concerns about Bolus Dose Pressors Patient safety concerns in regards to mixing agent, proper intermittent dosing Bolus dose pressors should not replace the role of fluid resuscitation, or transfusion! Editorial pointed out several dosing errors, blamed FOAMed for this Several response editorials pointed out errors were those of communications and had no connection to any FOAMed information 9 Department Name Month X, 201X
Bolus Dose Pressors in EMS Benefits: Paramedic ambulances already carry code epinephrine Mixing epinephrine for bolus dose less time consuming than mixing pressor for drips, using infusion pump etc. May help temporize the effects of shock during short transports Does not require central line access Risks: No evidence of improved morbidity/mortality Medication dilution and push doses of potent medication with opportunities for provider error and potential patient harm 10 Department Name Month X, 201X
Phenylephrine as a Bolus Dose Pressor Utilization began in anesthesiology It will not cause local tissue damage if extravasation Onset of action: within one minute Duration of action: five minutes Pure alpha effect No inotropic effect 11 Department Name Month X, 201X
Mixing, Administrating bolus dose Phenylephrine 1. Draw up 1 ml from 10 mg/ml phenylephrine vial 2. Inject that 1 ml into 100mL bag of Normal Saline This results in 10 mg phenylephrine in 100 ml = 100 mcg/ml 3. Draw up into a labeled syringe. ( phenylephrine 100 mcg/ml ) Dose of 0.5 ml-2 ml every 2-5 minutes (50-200 mcg/dose) Always confirm with pharmacist and verify doses prior to use -https://emcrit.org/racc/bolus-dose-pressors/ 12 Department Name Month X, 201X
Epinephrine as a Bolus Dose Pressor Will not cause damage when extravasating at concentration used Onset of action: 1 minute Duration of action: 5-10 minutes Affects: alpha, beta-1, and beta-2 receptors 13 Department Name Month X, 201X
Mixing and Administering bolus dose Epinephrine Two options: Both require diluting from cardiac epi preload AKA code epi AKA 1:10,000 epinephrine AKA 100 mcg epinephrine/ml AKA 1mg epinephrine/10ml DO NOT use 1:1000 14 Department Name Month X, 201X
Mixing and Administering bolus dose Epinephrine Option number 1: 1. Take a 10mL Normal Saline flush and waste 1mL This gives you 9mL of normal saline. (label epinephrine 10mcg/mL ) 2. Using a three way stopcock, add 1 ml(100 mcg) from cardiac epinephrine to the 9 ml Normal Saline syringe This gives you 100mcg of epinephrine in 10 ml of normal saline AKA 10 mcg epinephrine/ ml Dose of 0.5-2 ml every 2-5 minutes (5-20 mcg epinephrine/dose) Always confirm with pharmacist and verify doses prior to use -https://emcrit.org/racc/bolus-dose-pressors/ 15 Department Name Month X, 201X
Mixing and Administering bolus dose Epinephrine Option number 2: 1. Take cardiac epinephrine syringe(1mg epinephrine/10ml) and waste 9 ml This gives you 100 mcg of epinephrine in 1mL. (label epinephrine 10mcg/mL ) 2. Draw up 9 ml of Normal saline from a bag into the syringe This gives you 100mcg of epinephrine in 10 ml of normal saline AKA 10 mcg epinephrine/ ml Dose of 0.5-2 ml every 2-5 minutes (5-20 mcg epinephrine/dose) Always confirm with pharmacist and verify dose prior to use 16 Department Name Month X, 201X
Summary Always verify dilution process and doses with pharmicist prior to implementing a mixing procedure (They mix and dilute medications for a living!) The use of bolus dose pressors in anesthesia is old, the use in emergency medicine and EMS is new The use of bolus dose pressors may help temporize shock while en route to the hospital. (In addition to fluid boluses per local protocol) 17 Department Name Month X, 201X
Summary Continued The use of phenylephrine and epinephrine are most appropriate for bolus dose pressors in emergency medicine Always label mixed syringes and double check math with partner Never dilute 1 mg/1ml epinephrine for use as bolus dose pressor. (only 1mg/10 ml epinephrine) 18 Department Name Month X, 201X
References Weingart S. Upstairs care downstairs: delayed sequence intu- bation (DSI) [Internet]. Dallas, TX: American College of Emer- gency Physicians; 2010 [cited 2015 Mar 2]. Available from: http://www.acep.org/clinical---practice-management/up- stairs-care-downstairs--delayed-sequence-intubation-(dsi) Weingart s,. Push-dose Pressors for immediate blood pressure control. Clin Exp Emerg Med 2015;2(2):131-132 Cole JB Bolus-Dose Vasopressors in the Emergency Department: First, Do No Harm; Second, More Evidence Is Needed. Annals of Emergency Medicine. 71(1) 2018 93-95 Awad Response to Medication errors with push dose pressors in the emergency department and intensive care units. American Journal of Emergency Medicine, In press. Selde w. Push Dose Epinephrine as a Temporizing Measure for Drugs Causing Hypotension. JEMS 9/15/14 Genes N. Pushing Back on Push Dose Pressors. Emergency Physicians Monthly. http://epmonthly.com/article/pushing-back-push-dose-pressors/ accessed 3/3/18 Coralic Z. The Dirty Epi Drip: IV epinephrine When you Need it. Academic Life in Emergency Medicine 6/2013. https://www.aliem.com/2013/06/dirtyepi/ accessed 3/3/18 19 Department Name Month X, 201X