Push Dose Pressors

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Why Use Push Dose Pressors?

To buy yourself some time with your super hypotensive patients!!
Ensure your patient’s perfusion status while you are trying to:
  • 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)

Onset Immediate – 1 minute
Duration 5-10 minutes
Dose 5-20mcg every 2-5 minutes (0.5-2mL)

Preparation
  • 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

alpha 1 agonist = increase in peripheral vascular resistance
Heart rate remains the same. Watch out for reflex bradycardia.

Phenyelphrine Push Dose Concentration 100mcg/mL

Onset Immediate – 1 minute
Duration 10-20 minutes
Dose 50-200mcg every 2-5 minutes (0.5-2mL)

Preparation
  • 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

Beta Receptors
Tissue
Receptor Subtype
Heart
beta1
Adipose Tissue
beta1, beta3?
Vascular Smooth Muscle
beta2
Airway Smooth Muscle
beta2
Beta1 Agonist
Increases contractile force & HR. Activation of beta1 receptors in the atria and ventricles but the ventricles are really effected – thus increasing myocardial contraction. HR increases because SA node, AV node and the His-Purkinjie system are activated.

Beta 2 Agonist
Relaxes smooth muscles

Alpha1 & Alpha 2 Agonist
  • Constriction of vascular smooth muscle.
  • Myocardial Alpha 1 may have a positive inotropic effect.
  • No clear understanding on Alpha 2 receptors at this moment.
Epinephrine & NE has equal affinity to both alpha 1 and alpha 2 receptors.  However, Epinephrine has a higher affinity to beta 2 receptors. So effects are dose dependent. Initially will activate beta 2 receptors so relaxes vascular smooth muscle and decrease peripheral resistance, but at higher doses, epinephrine will also bind to alpha 1 receptors which is a potent vasoconstrictor and will dominate as epinephrine concentrations are higher.

Phenylephrine is a pure alpha 1 agonist.
  • 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

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/ ].

4 thoughts on “Push Dose Pressors

  1. 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.

  2. 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!

  3. 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.

  4. Great post, one minor editorial comment. You have concentration listed as dosage for both epi and phenylephrine.