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The Use of Bolus-Dose Vasopressors in the Emergency Department

While bolus-dose vasopressors are commonly used in critical care medicine and anesthesiology to treat patients with hypoperfusion, its application in emergency medicine is minimal with little penetration into daily care.

Emergency Medicine. 2018 March;50(3):72-76 | 10.12788/emed.2018.0085

Author(s):

Sabrina Weigand, MD

J. Nate Hedrick, PharmD

William J. Brady, MD

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References

1. Weingart S. EMCrit podcast 6—push-dose pressors. EMCrit RACC Web site. July 2009. https://emcrit.org/racc/bolus-dose-pressors. Accessed March 12, 2018.

2. Weingart S. EMCrit podcast 205—push-dose pressors update. EMCrit RACC Web site. August 2017. https://emcrit.org/racc/push-dose-pressor-update/. March 12, 2018.

3. Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med. 2015;2(2):131-132. doi:10.15441/ceem.15.010.

4. Acquisto NM, Bodkin RP, Johnstone C. Medication errors with push dose pressors in the emergency department and intensive care units. Am J Emerg Med. 2017;35(12):1964-1965. doi:10.1016/j.ajem.2017.06.013.

5. Holden D, Ramich J, Timm E, Pauze D, Lesar T. Safety considerations and guideline-based safe use recommendations for “bolus-dose” vasopressors in the emergency department. Ann Emerg Med. 2018;71(1):83-92. doi:10.1016/j.annemergmed.2017.04.021.

6. Brunauer A, Koköfer A, Bataar O, Gradwohl-Matis I, Dankl D, Dünser MW. The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients: a retrospective cohort study. Crit Care. 2014;18(6):719. doi:10.1186/s13054-014-0719-2.

7. Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of bolus-dose phenylephrine for peri-intubation hypotension. J Emerg Med. 2015;49(4):488-494. doi:10.1016/j.jemermed.2015.04.033.

8. Gottlieb M. Bolus dose of epinephrine for refractory post-arrest hypotension. Can J Emerg Med. 2017;409:1-5. doi:10.1017/cem.2016.409.

9. Schwartz MB, Ferreira JA, Aaronson PM. The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting. Am J Emerg Med. 2016;34(12):2419-2422. doi:10.1016/j.ajem.2016.09.041.

10. Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of bolus-dose phenylephrine for peri-intubation hypotension. J Emerg Med. 2015;49(4):488-494. doi:10.1016/j.jemermed.2015.04.033.

11. Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30:653.e9-e17.

12. Kanwar M, Irvin CB, Frank JJ, et al. Confusion about epinephrine dosing leading to iatrogenic overdose: A life-threatening problem with a potential solution. Ann Emerg Med. 2010;55:341-344.

The use of bolus-dose vasopressors in anesthesiology and other areas of critical care medicine is well known. This common medical intervention, however, is not often employed in emergency medicine (EM). Bolus-dose vasopressors are defined as the administration of small bolus doses of vasopressor agents, such as epinephrine or phenylephrine, to patients with compromised perfusion who continue to have a pulse (ie, these patients are not in cardiac arrest). This intervention is considered as a temporizing measure for transient hypotension or as a bridge to more definitive therapy.

Clinical Application

Bolus-dose vasopressive therapy is also referred to as push-dose pressor (PDP) therapy—a term coined by Weingart.^1-3 Theoretically, any vasopressor could be used in a mini-dose, bolus fashion, though in current clinical practice, anesthesiologists primarily employ ephedrine, epinephrine, and phenylephrine. Two of these agents are likely more appropriate for the ED, including epinephrine and phenylephrine. Both of these agents have a short half-life and therefore an abbreviated period of effect. In addition, dosing and related administration of epinephrine and phenylephrine is relatively straightforward. Moreover, most emergency physicians and nurses are quite familiar with both agents.

With respect to ephedrine, due to its longer half-life, complex dosing regimen, and associated higher-incidence of cardiovascular (CV) complications, its use is likely not appropriate in the ED as a bolus-dose vasopressor.

Epinephrine and Phenylephrine

Epinephrine is a potent sympathomimetic agent with alpha- and beta-receptor activity. In addition to its vasopressor effects, epinephrine is also an inotropic and chronotropic agent, increasing cardiac output, heart rate (HR), and systemic vascular resistance, which can markedly improve perfusion. Epinephrine also can be given to patients with hypoperfusion and/or shock due to low-cardiac output with or without vasodilation, lacking significant tachycardia.

Phenylephrine is a pure alpha agonist and therefore does not appreciably affect cardiac output and HR, but does significantly increase systemic vascular resistance and thus systemic perfusion. Phenylephrine can be used to treat patients with hypoperfusion and/or shock states due to vasodilation with coexistent, significant tachycardia.

Preparation and Administration

The preparation and dosing of push-dose epinephrine and phenylephrine are not particularly complex. Many clinicians recommend the pre-mixed, manufacturer-prepared agents for PDP therapy. These premixed formulations not only facilitate administration, but also reduce the chance of a preparation error that can result in incorrect dosing.^3-5 If pre-mixed formulations are not available, clinicians can readily prepare epinephrine and phenylephrine for PDP use.

Push-Dose Epinephrine. Clinicians can prepare epinephrine for push-dose administration as follows:^1-3

Obtain 1 mL of epinephrine 1:10,000 (ie, 0.1 mg/mL or 100 mcg/mL);
Obtain a 10 mL syringe of normal saline and remove 1 mL;
Inject the 1 mL of epinephrine 1:10,000 (100 mcg/mL) into this syringe containing 9 mL of normal saline; and
Result: 10 mL of epinephrine (10 mcg/mL), with each 1 mL of this solution containing 10 mcg of epinephrine.

Administration of push-dose epinephrine (10 mcg/mL) produces effect within 1 minute of use with a duration of approximately 5 to 10 minutes. Dosing at this concentration ranges from 0.5 to 2.0 mL every 2 to 5 minutes, delivering 5 to 20 mcg.^1-3Push-Dose Phenylephrine. To prepare phenylephrine for push-dose administration, clinicians may use the following approach:^1-3

Obtain 1 mL of phenylephrine (10 mg/mL concentration);
Inject this 1 mL of phenylephrine (10 mg/mL) into a 100 mL bag of normal saline; and
Result: 100 mL of phenylephrine (100 mcg/mL), with each 1 mL of this solution containing 100 mcg of phenylephrine.

Administration of push-dose phenylephrine (100 mcg/mL) produces effect within 1 minute of use with a duration of approximately 10 to 20 minutes. Dosing at this concentration ranges from 0.5 to 2.0 mL every 2 to 5 minutes, delivering 50 to 200 mcg.^1-3Alternative Push-Dose Preparations for Phenylephrine. Two other methods of preparing phenylephrine for bolus-dose administration include the following: (1) the addition of phenylephrine 20 mg to a bag of 250 cc of normal saline, resulting in an 80 mcg/mL concentration; and/or (2) phenylephrine (20 mg) is commercially available for continuous infusion in a 250 mL bag of normal saline, yielding the same concentration of 80 mcg/mL; in either case, medication can be drawn up and administered. Dosing at this concentration ranges from 0.5 to 2.5 mL every 2 to 5 minutes, delivering 40 to 200 mcg. Lastly, phenylephrine is also commercially available in pre-made mixtures, specifically manufactured for bolus-dose therapy.