Push dose pressors: Experience in critically ill patients outside of the operating room

Rotando, Andrew; Picard, Lindsey; Delibert, Samantha; Chase, Karin; Jones, Courtney Marie Cora; Acquisto, Nicole M.

doi:10.1016/j.ajem.2018.12.001

Cited by 24 publications

(32 citation statements)

References 7 publications

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“…Prior studies evaluating phenylephrine pushes evaluated their use immediately before, during, and immediately after intubation; inside and outside the operating room; or in the ED. [5][6][7][8][9][10][11] Extrapolation of these prior studies to patients in the ICU is difficult, particularly for patients with septic shock. The results of our study showed that phenylephrine pushes did not impact the time to achieving sustained hemodynamic stability (HR, 1.34; 95% CI, 0.98-1.84) within 12 h after norepinephrine initiation, but were associated with higher odds of hemodynamic stability at 3 h (OR, 1.8; 95% CI, 1.09-2.97).…”

Section: Discussionmentioning

confidence: 99%

“…4 Phenylephrine, epinephrine, and ephedrine are the agents most commonly used as push dose vasopressors and have been evaluated in small studies in the operating room, in the ED, during the peri-intubation period, and in only limited descriptive studies in the ICU. [5][6][7][8][9][10][11] These studies have demonstrated significant heterogeneity in use and limited safety data with this practice. [5][6][7][8][9][10][11] At our health-care system, phenylephrine pushes are used in practice with the objective of rapid achievement of goal MAP in emergent situations.…”

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confidence: 99%

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Effect of Phenylephrine Push Before Continuous Infusion Norepinephrine in Patients With Septic Shock

Hawn

Bauer

Yerke

et al. 2021

Chest

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Effect of Phenylephrine Push Before Continuous Infusion Norepinephrine in Patients With Septic Shock

Hawn

Bauer

Yerke

et al. 2021

Chest

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“…We found a mean increase from baseline in all hemodynamic parameters with the use of PDP: systolic blood pressure increased by 41.3%; diastolic blood pressure increased by 44.3%; and mean arterial pressure increased by 35.1%. Rotando et al 13 evaluated PDP practice patterns and sought to determine the efficacy in hospitalized hypotensive patients outside of the operating room. Results show a mean increase in systolic blood pressure of 32.5% and a mean increase in diastolic blood pressure of 27.2%.…”

Section: Discussionmentioning

confidence: 99%

Push-Dose Pressors During Peri-intubation Hypotension in the Emergency Department: A Case Series

Bakhsh

Alotaibi

2021

Clinical Practice and Cases in Emergency Medicine

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Introduction: Emergency physicians frequently encounter critically ill patients in circulatory shock requiring definitive airway procedures. Performing rapid sequence intubation in these patients without blood pressure correction has lethal complications. Questioning the efficacy and fearing side effects of push-dose pressors (PDP) has created an obstacle for their use in the emergency department (ED) setting. In this case series we describe the efficacy and side effects of PDP use during peri-intubation hypotension in the ED. Case series: We included 11 patients receiving PDPs in this case series. The mean increase in systolic blood pressure was 41.3%, in diastolic blood pressure 44.3%, and in mean arterial pressure 35.1%. No adverse events were documented in this case series. Conclusion: The use of push-dose pressors during peri-intubation hypotension may potentially improve hemodynamic status when used carefully in the ED.

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“…In ED, intensive care unit, and operating room settings, bolus dose IV epinephrine has been shown to be safe and effective in augmenting hypotension. [9][10][11][12][13][20][21][22] Bolus dose epinephrine has also been studied in the prehospital HEMS and critical care transport settings, 16,17 but this study is the first to evaluate prehospital bolus dose epinephrine for hypotensive patients in a ground-based EMS service. Even transient peri-intubation hypotension is known to increase mortality in the hospital setting, 5 and mortality benefit has been noted with earlier initiation of vasopressor therapy in septic shock patients as well.…”

Section: Discussionmentioning

confidence: 99%

Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport

Patrick

Ward

Anderson

et al. 2020

Prehosp. Disaster med.

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Background: The utility and efficacy of bolus dose vasopressors in hemodynamically unstable patients is well-established in the fields of general anesthesia and obstetrics. However, in the prehospital setting, minimal evidence for bolus dose vasopressor use exists and is primarily limited to critical care transport use. Hypotensive episodes, whether traumatic, peri-intubation-related, or septic, increase patient mortality. The purpose of this study is to assess the efficacy and adverse events associated with prehospital bolus dose epinephrine use in non-cardiac arrest, hypotensive patients treated by a single, high-volume, ground-based Emergency Medical Services (EMS) agency. Methods: This is a retrospective, observational study of all non-cardiac arrest EMS patients treated for hypotension using bolus dose epinephrine from September 12, 2018 through September 12, 2019. Inclusion criteria for treatment with bolus dose epinephrine required a systolic blood pressure (SBP) measurement <90mmHg. A dose of 20mcg every two minutes, as needed, was allowed per protocol. The primary data source was the EMS electronic medical record. Results: Forty-two patients were treated under the protocol with a median (IQR) initial SBP immediately prior to treatment of 78mmHg (65-86) and a median (IQR) initial mean arterial pressure (MAP) of 58mmHg (50-66). The post-bolus SBP and MAP increased to 93mmHg (75-111) and 69mmHg (59-83), respectively. The two most common patient presentations requiring protocol use were altered mental status (55%) and respiratory failure (31%). Over one-half of the patients treated required both advanced airway management (62%) and multiple bolus doses of vasopressor support (55%). A single episode of transient severe hypertension (SBP>180mmHg) occurred, but there were no episodes of unstable tachyarrhythmia or cardiac arrest while en route or upon arrival to the receiving hospitals. Conclusion: These preliminary data suggest that the administration of bolus dose epinephrine may be effective at rapidly augmenting hypotension in the prehospital setting with a minimal incidence of adverse events. Paramedic use of bolus dose epinephrine successfully increased SBP and MAP without clinically significant side effects. Prospective studies with larger sample sizes are needed to further investigate the effects of prehospital bolus dose epinephrine on patient morbidity and mortality.

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Push dose pressors: Experience in critically ill patients outside of the operating room

Cited by 24 publications

References 7 publications

Effect of Phenylephrine Push Before Continuous Infusion Norepinephrine in Patients With Septic Shock

Effect of Phenylephrine Push Before Continuous Infusion Norepinephrine in Patients With Septic Shock

Push-Dose Pressors During Peri-intubation Hypotension in the Emergency Department: A Case Series

Prehospital Efficacy and Adverse Events Associated with Bolus Dose Epinephrine in Hypotensive Patients During Ground-Based EMS Transport

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