Why Use Push Dose Pressors?
- intubate
- managing transient hypotension
- preparing a drip
- preparing a central line
Know which medication to use based on clinical presentation of patient.
Dr. Scott Weingart’s Easy Push Dose Printout (It has photos!)
Epinephrine
alpha 1&2, beta 1&2 agonist = inopressor
(Increase in myocardial contraction, heart rate, and peripheral vascular resistance)
Epinephrine Push Dose Concentration 10mcg/mL (1:100,000) vs. cardiac dose (1:10,000)
- Draw up 9mL of Normal Saline in an empty 10mL syringe (updated – see below)
- Attach a syringe and draw up 1mL of epinephrine from the pre-filled cardiac dose amp (Epinephrine 100mcg/mL)
- Shake a little, Place a label: Epinephrine 10mcg/mL
Phenylephrine
- Draw up 1mL of phenylephrine (10mg/mL concentration vial)
- Inject into NS 100mL bag
- Shake a little, Place a label: Phenylephrine 100mcg/mL
- Use as a drip or draw up in a syringe.
Super Nerdy Receptor Information
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Tissue
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Receptor Subtype
|
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Heart
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beta1
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Adipose Tissue
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beta1, beta3?
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Vascular Smooth Muscle
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beta2
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Airway Smooth Muscle
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beta2
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- Constriction of vascular smooth muscle.
- Myocardial Alpha 1 may have a positive inotropic effect.
- No clear understanding on Alpha 2 receptors at this moment.
- Vasoconstriction of both arterial and venous vessels.
- Great for someone who has tachycardia/tachyarrhythmia but also hypotensive.
- Can cause reflex bradycardia.
Update 8/6/2017 “Concentration” used to differentiate final concentration versus dosing, to have clear language.
Update 8/8/2017 Brought to my attention by Craig Button, RN – There have been reported cases of serious medication errors due to mixing medications using pre-filled saline flushes and not labeling them. Therefore, I am going to change the recommended preparation of mixing epinephrine push dose concentrations. The LAST thing I want is to hear about unlabeled saline flushes with epinephrine lying around, and/or causing harm to patients. These medications should be respected so PLEASE LABEL ALL PREPARATIONS!! Original text is here. Blog post has been updated above.
- Original Text: Epinephrine Push Dose Concentration Preparation
- Take a NS 10mL flush and squeeze out air bubbles and saline so 9mL remains
- Attach a syringe and draw up 1mL of epinephrine from the pre-filled cardiac dose amp (Epinephrine 100mcg/mL)
- Shake a little, Place a label: Epinephrine 10mcg/mL
Now listen to the episode….
References:
Scott Weingart. EMCrit Podcast 6 – Push-Dose Pressors. EMCrit Blog. Published on July 10, 2009. Accessed on August 3rd 2017. Available at [https://emcrit.org/emcrit/bolus-dose-pressors/ ].
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[…] Cee Dirsa talks push dose pressors to ensure your patient is perfusing while you are preparing a drip. […]
It’s generally considered bad practice (or not best practice) to use profiled flushes as the mix syringe. It doesn’t take that long to grab a 10cc syringe and add to it. There have been to many med errors over the years by both RN’s and MDs/DOs using flush syringes. It’s a shortcut and although you may have been doing it successfully for years, all it takes it one oops.
I’ve seen cases of paralytic, induction agent, etc, being pushed accidentally.
The Key is most cases is being prepared. I always grab and mix an Epi syringe when the residents are intubating, just in case. I’ve even worked places that pharmacy mixes phenylephrine stick and left in fridge for us. Just in case.
Hi @craigb.rn, I don’t think it’s bad practice to use a pre-filled NS 10mL syringe in this situation because it is a quick and effective method (and less math and steps) to prepare push dose medication – and it is labeled. It’s no different than preparing medication that is diluted in a pre-filled NS 50mL bag and putting a label over that. The key is to label appropriately – put the medication name and concentration before use. I don’t see this as a shortcut.
I never administer medications that are not labeled correctly or saline flushes that are not in the individual packaging – it’s a workflow that I personally use to prevent medication errors…along with right patient, DOB, MRN, right order, etc.
Great post, one minor editorial comment. You have concentration listed as dosage for both epi and phenylephrine.
Hello tcrowejr! Thank you for this – I completely agree it was not clear. I fixed it so that it’s clear it’s the concentration for a push dose, and not the actual dose. Thanks!