Comparison of push-dose phenylephrine and epinephrine in the emergency department

Nam, Elizabeth; Fitter, Scott; Moussavi, Kayvan

doi:10.1016/j.ajem.2021.11.033

Cited by 10 publications

(2 citation statements)

References 28 publications

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“…The lack of prophylactic vasopressor administration’s effect on peri-intubation hypotension was contrary to our hypothesis and unexpected given that bolus dose vasopressors have been shown to reduce hypotension in the setting of elective intubation in the operating room ( 15 – 21 ) and increase systolic blood pressure among critically ill patients in the ED ( 33 ) and ICU ( 34 ). Our definition of prophylactic vasopressors included two distinct interventions: 1) administration of bolus dose prophylactic vasopressors in patients not on vasopressors infusions prior to enrollment and 2) bolus dose or increasing the dose of vasopressors in patients already receiving vasopressor infusions prior to enrollment.…”

Section: Discussioncontrasting

confidence: 92%

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Fuchita

Pattee

Russell

et al. 2023

Critical Care Explorations

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OBJECTIVE: Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes. DESIGN: A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. SETTING: Seven emergency departments and 17 ICUs across the United States. PATIENTS: One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (–12 vs –11 mm Hg; p = 0.66). CONCLUSIONS: The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.

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Section: Discussioncontrasting

confidence: 92%

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Fuchita

Pattee

Russell

et al. 2023

Critical Care Explorations

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“…18,27,28 Despite the above evidence, push-dose phenylephrine is used to a greater degree than push-dose ephedrine in the critically ill. 6,11 Reasons cited for this include dosing/medication errors and adverse hemodynamic events when using agents with inotropic potential such as epinephrine or ephedrine, although 1 study suggests that these errors can be mitigated if there is an established protocol in place to reduce these adverse events. 18,[29][30][31] Ephedrine, in particular, may be less than ideal in the critical care population due to its primary mode of action relying on endogenous catecholamines which may be depleted in this population. Interestingly, 1 study in surgical patients undergoing general anesthesia in the prone position demonstrated that ephedrine produced not only increases in cardiac output/index, but a more persistent pressor response as compared to phenylephrine when used as bolus injection.…”

Section: Discussionmentioning

confidence: 99%

Noninvasive Cardiac Output Monitoring (NICOM) in the Critically Ill Patient Undergoing Endotracheal Intubation: A Prospective Observational Study

Smischney

Stoltenberg

Schroeder

et al. 2023

J Intensive Care Med

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Background: Cardiovascular instability occurring during endotracheal intubation (ETI) in the critically ill is a commonly recognized phenomenon. However, this complication has not been evaluated in terms of the physiological cause (ie, decreased preload, contractility, or afterload) leading to the instability. Thus, the aim of the current investigation was to describe the hemodynamics occurring during ETI with noninvasive physiologic monitoring and to collect preliminary data on the hemodynamic effects of induction agents and positive pressure ventilation. Methods: A multicenter prospective study enrolling adult (≥18 years) critically ill patients undergoing ETI with noninvasive cardiac output monitoring in a medical/surgical intensive care unit from June 2018 to May 2019 was conducted. This study used the Cheetah Medical noninvasive cardiac output monitor to collect hemodynamic data during the peri-intubation period. Additional data collected included baseline characteristics such as illness severity, peri-intubation pharmacologic administration, and mechanical ventilation settings. Results: From the original 27 patients, only 19 (70%) patients had complete data and were included in the final analysis. Propofol was the most common sedative 8 (42%) followed by ketamine 6 (32%) and etomidate 5 (26%). Patients given propofol demonstrated a decrease in total peripheral resistance index (delta change [dynes × s/cm−5/m2]: −2.7 ± 778.2) but stabilization in cardiac index (delta change (L/min/m2]: 0.1 ± 1.5) while etomidate and ketamine demonstrated increases in total peripheral resistance index (etomidate delta change [dynes × s/cm−5/m2]: 302.1 ± 414.3; ketamine delta change [dynes × s/cm−5/m2]: 278.7 ± 418.9) but only etomidate resulted in a decrease in cardiac index (delta change [L/min/m2]: −0.3 ± 0.5). Positive pressure ventilation resulted in minimal changes to hemodynamics during ETI. Conclusions: The current study demonstrates that although propofol administration leads to a decrease in total peripheral resistance index, cardiac index is maintained while etomidate leads to a decrease in cardiac index with both etomidate and ketamine increasing total peripheral resistance index. These hemodynamic profiles are minimally affected by positive pressure ventilation. Study registration: ClinicalTrials.gov ID, NCT03525743.

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Epinephrine

2022

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Comparison of push-dose phenylephrine and epinephrine in the emergency department

Cited by 10 publications

References 28 publications

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Noninvasive Cardiac Output Monitoring (NICOM) in the Critically Ill Patient Undergoing Endotracheal Intubation: A Prospective Observational Study

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