Back to Basics: Push Dose Vasopressors
Push Dose Vasopressors Say What?!
By: Rachel Rafeq, PharmD
You are responding to a cardiac arrest and the patient has achieved return of spontaneous circulation however his blood pressure drops to 68/40 mmHg. You would like to use push dose epinephrine. How is this prepared?
Preparation:
1) Draw up 1 mL of epinephrine (0.1 mg/mL) from bristojet
2) Discard 1 mL of 0.9% sodium chloride (NaCl) from flush
3) Add 1 mL of drawn up epinephrine to the remaining 9 mL of NaCl to make a total volume of 10 mL
a. Final concentration: epinephrine 0.01 mg/mL (10 mL syringe)
b. Dose: 0.005-0.02 mg (0.5-2 mL) every 2-5 minutes
Medication Safety Points:
• Epinephrine 1 mg/mL vials can NOT be used. Use of this vial to prepare the medication will result in a 10-fold overdose (note the different concentrations between the bristojet and vial)
• LABEL SYRINGE!! to avoid erroneous administration of this syringe to this or another patient with the assumption that this is a flush
Indication:
• Hypotension
o Temporizing measure for hypotension or post intubation hypotension
• Tissue perfusion
o improve perfusion to vital organs or maintain perfusion which is often impaired after return of spontaneous circulation
Mechanism of action:
• Epinephrine stimulates alpha and beta receptors. Alpha activity allows it to act as a vasopressor and beta activity allows it to act as an inotrope.
o Vasopressor: increases peripheral vascular resistance > improve blood pressure
o Inotrope: increases myocardial contraction > improve heart rate
o Risk of tachycardia; avoid use in patients with tachycardia or tachyarrhythmia > Use phenylephrine in these patients
Alternative Agent:
• Phenylephrine 100 mcg/mL
o Dose: 50-200 mcg (0.5-2 mL) every 2-5 minutes
o Mechanism: stimulates alpha activity; acts as a pure vasopressor > Risk of reflex bradycardia
o Preparation:
1. Draw up 1 mL of phenylephrine 10 mg/mL vial into a 3 mL syringe
2. Inject this into a 100 mL bag of 0.9% sodium chloride. LABEL BAG
3. Draw up 10 mL from bag into 10 mL syringe and LABEL syringe
• Final concentration phenylephrine 100 mcg/mL (0.1 mg/mL)
References:
1) https://www.sciencedirect.com/science/article/pii/S0196064417304754?via%...