Push Dose Pressors – The Full Safety Dance


I’m not a powerful Jedi Master with Force Visions and frankly, unable to see into the future. Hello Star Wars fans!

This is a follow-up bonus episode in response to Episode 5 Push Dose Pressors, listeners’ questions, and also in light of recent journal articles that recently got published. Timing was completely coincidental when Episode 5 Push Dose Pressor podcast episode was released.

Although I’ve been using push dose pressors for years now, I still researched the topic awhile ago. Frankly, there wasn’t much out there – and there still isn’t. Why? Because it’s not standard of care. But I suspect it will be once there are RCTs and more research and we all know that takes time. Meanwhile, this is a practice that is happening in our Emergency Departments and as ED nurses, we definitely should know about them.

This is the initial reason for a push dose pressor episode on this podcast. Nurses, we are going to be the ones mixing and preparing the push dose pressors, and a good chance we will be administering it. These medications, epinephrine and phenylephrine, are extremely potent and should be highly respected when used.  It also warrants an increased awareness of the entire process – including when to use them, and what safety measures we can use to prevent medication errors.

So let’s go over some safety measures that will ensure the correct utilization of push dose pressors. 

1. Mixing/Preparing Epinephrine Push Dose Pressor

Let’s start with preparing an epinephrine push dose pressor – After I had released my podcast, a nurse listener, immediately brought to my attention that using pre-filled saline flushes to prepare the epinephrine push dose concentration is bad because it can lead to medication errors. I definitely argued that I don’t see the difference between using a pre-filled saline flush for a push dose pressor versus a pre-filled saline bag for a drip – as long as it is labeled properly (use concentration doses).

More responses came and a major safety issue came up that health care providers are NOT labeling their syringes after mixing – why??!!  And there has been reported errors in medication where health care providers are mistakenly pushing what they think is a NS flush syringe – but it actually has medication in them (epinephrine or other medications).

This gave me a heavy heart – and you know, I wanted to puke a little bit. I hope you all can forgive me. The last thing I would ever want to endorse is an unsafe practice, or a practice that can lead to even more errors. That being said, I will change my own practice to draw up epinephrine in an empty syringe and dilute it to a proper push dose concentration – and immediately label the syringe afterwards.

Never let that syringe out of your hands or eyesight until the label is securely on the syringe.

Epinephrine is a medication that is prone to errors to begin with.

Some additional tips on mixing:

Always label where you can still see your mL markings on the syringe – it’s important that way you know how much you are giving! This also applies to other medications like your intubation meds..

Why Use Cardiac Pre-filled Syringes?
You may wonder why it is recommended to mix from a cardiac pre-filled syringe – it’s because you can guarantee the concentration (1:10000 with 10mL). Many medication rooms will have different concentrations stocked 1:1000 for anaphylaxis or 1:10000 for cardiac arrest – but both are in 1mL vials. If you were to grab the vial of Epinephrine 1:10000 in 1mL – you are supposed to further dilute that before administering.

So when your patient is crashing, to prevent thinking it even further, it’s easier to grab the cardiac pre-filled syringe because you know it will have a concentration of 1:10000 in 10mL.

Maintain Sterility
When mixing, try to maintain sterility as much as possible. Remember all medications will go into the blood stream, we do not want to introduce more problems. This is basic nursing practice.

NS Bags and Flushes
On a side note, Just like how you wouldn’t give a patient NS boluses or mix medication where the NS saline bag has been opened from the outside packaging, you shouldn’t be using NS saline syringes that are not individually wrapped – you should open the NS syringes yourself.

Pharmacist Prepared Pressor
On the subject of having a pharmacist prepare your push dose pressor. I personally have not found this to be helpful in the clinical setting. My patient cannot wait 20-30 minutes for the push dose pressor to come down – the usefulness of the push dose pressor has sailed.  That is why I prepare it myself.  If I have to choose between a continuous drip and a push dose pressor – I would choose the drip. Just titrate it to effect! You may have to start the NE drip on a higher dose like 10 or 15 mcg/min.  You may be able to eliminate the use of a push dose pressor all together.

Pre-mixed and Pre-filled Push Dose Pressor in Syringes
Finally, it is not looking like it is possible to have pre-filled epinephrine push dose pressor syringes prepared and stocked in a medication room because of stability issues. Phenylephrine can be pre-mixed and stored but not epinephrine. This may change in the future but this is the case now. Any Pharm D listeners who can respond to this?

2. Push Dose Pressor do NOT replace Standard Therapy

Push dose Pressors (PDP) are not to be used in replacement of standard therapy –  which are vasopressor drips.  PDP are meant to be used because your patient is so hypotensive that they may code on you before you can get the vasopressor drip running. How often does this happen?  Not that often. In these situations with your really bad hypotensive patients – the goal is to get that continuous drip infusing. I can get a NE drip infusing in about 5-8 minutes.

You will never see me standing using push dose pressors in lieu of a continuous vasopressor drip. What you will see me do is if there was a problem or delay in getting the drip, push dose pressors will save me because I can administer small doses as described until that drip is ready and infusing.

Another example is I would have a NE drip infusing and I have to wait for a vasopressin drip to come down from pharmacy and it has been decided after re-evaluation that the answer is a vasopressin drip and not another cause for hypotension – a push dose pressor may be indicated to keep the MAP up for perfusion.  This is meant as another adjunct tool – but not as a replacement therapy. Think of it as another tool in your tool belt. Use if needed.

3. Communication

Clear language and communication is required when it comes to using push dose pressors. The problem is that like stated earlier, this is not a common occurrence – so the language is new or not used often. We have all learned the closed loop communication – this is a great time to exercise it – your patient doesn’t have to be coding to use it. I propose that an order, usually verbal, goes something like this:

  1. Provider: I want an Epinephrine push dose pressor concentration mixed. That is the 10mcg/mL concentration. Not the cardiac arrest dose.
  2. Nurse: Okay, I will prepare an Epinephrine push dose pressor concentration that is 10mcg/mL.

Providers: Do NOT give orders by volume.

  • Ex: “I want 1mL of Epinephrine.”
  • 1mL of what concentration? Nurses, feel free to ask your providers this question immediately! NEVER ASSUME.

Providers – please don’t ever give verbal orders by volume – use the dosage. And if it’s extremely chaotic and you can’t remember the dosage – say, PUSH DOSE PRESSOR CONCENTRATION, NOT THE CARDIAC ARREST DOSE.

Remember, Epinephrine is used in so many ways (i.e.)

  • Aerosol for asthma
  • IM/IV for anaphylaxis (lots of medication errors here too)
  • Cardiac Arrest
  • Drips
  • Push Dose Pressor

Once you and your team are more versed in utilizing push dose pressors, it becomes more normal and the communication will get easier.

If you are going to use push dose pressors in your facility, you should train as a multidisciplinary approach that means both providers and nurses on how to utilize, prepare, and communicate utilizing push dose pressors.

As more time passes and thoughtful research is conducted on push dose pressors, we will have more evidence that will either support or not support its use.

Now onto the episode…