Push Dose Pressors

[VFlutter]

We used push dose neo extensively in the ICU and it is great in certain situations such as peri/post intubation hypotension or shocky patients while you are mixing drips however sometimes I think providers use it as a crutch and not properly resuscitate the patient. The classic "We gave 5 neo sticks on the way" so they maintain their pressure just long enough to arrest for you.

 

[ERDoc]

This has been "all the rage" in the SMACC/ FOAMED realm for the past few years.

I think it's worth a shot in certain situations such as what @TransportJockey mentions in his protocols above (I really do think Galveston EMS sounds more and more fitting for me).

Let's see what the good doc's spin on it is...
@ERDoc anyone?

This is where you get spoiled working in a hospital. Every hospital I work at has a clinical pharmacologist on 24/7 who can get anything ready pretty quick and EMS does not carry pressors so it is not something I have done much reading on. I don't see a problem with it, if it is all you have. In that case it is better than doing nothing.

 

[medichopeful]

I actually wrote a paper on the idea of push-pressors in paramedic school. I'm a huge fan (I've used them in the ICU too). They're awesome for people who don't necessarily need a drip (post-intubation hypotension), or to buy some time to set up a drip.

I know that Wake County has push-dose neo in their protocols and am rather envious of this (I'm doing ride time in Mass, so take that for what's it's worth).

Here's an EMCrit podcast on this:

http://emcrit.org/podcasts/bolus-dose-pressors/

 

[Bullets]

Yeah, I've heard of that. Dumb question, how do you pull it up? A flush won't screw directly into the Bristojet, right? They're both male connectors.

put the epi in a bristo, screw a med draw needle on the end, waste 1ml from a flush and push 1ml of epi into the flush

 

[VentMonkey]

However it's drawn up,it seems more than reasonable that this should be something taught to be the norm---as mentioned---in any post-ROSC/ severely hypotensive patients at the very least.

Particularly with shorter transport times when hanging drips seems time consuming, and less practical with these types of patients, specifically.

 

[TXmed]

With the growing popularity of this, it wouldnt suprise me if we saw epi 1:100 prefilled in a few years.

 

[Carlos Danger]

With the growing popularity of this, it wouldnt suprise me if we saw epi 1:100 prefilled in a few years.

You can find that in many hospitals.

 

[TXmed]

You can find that in many hospitals.

Interesting, ive havent seen it in the prehospital setting.

 

[Carlos Danger]

Interesting, ive havent seen it in the prehospital setting.

The only settings I've seen it used routinely is in cardiac surgery and ped anesthesia. But lots of hospital pharmacies stock it.

Ephedrine is essentially the same drug, and can be found anywhere. In anesthesia I've never seen or heard of anyone using epi routinely (outside of the aforementioned settings) because ephedrine is easier to use and so readily available.

I don't know why more people don't stock ephedrine rather than messing with epi.

 

[Brandon O]

I don't know why more people don't stock ephedrine rather than messing with epi.

Kinda longer acting, right?

What are the pharmacodynamics like (alpha/beta)?

 

[Carlos Danger]

Ephedrine is much longer acting than epi. It has both direct and indirect effects and is more alpha than beta, which is the opposite of epi, and is probably more useful for most clinical scenarios and it causes less tachycardia at equivalent doses. It's also "cleaner", in terms of having fewer effects on endogenous steroids and other hormones. Not emetogenic like epi is. The two drugs have similar effects on renal, coronary, and cerebral perfusion.

The only real advantage that epi has over ephedrine in most scenarios is that epi takes effect much quicker. Ephedrine takes a full minute or two.

 

[Brandon O]

Ephedrine is much longer acting than epi. It has both direct and indirect effects and is more alpha than beta, which is the opposite of epi, and is probably more useful for most clinical scenarios and it causes less tachycardia at equivalent doses. It's also "cleaner", in terms of having fewer effects on endogenous steroids and other hormones. Not emetogenic like epi is. The two drugs have similar effects on renal, coronary, and cerebral perfusion.

The only real advantage that epi has over ephedrine in most scenarios is that epi takes effect much quicker. Ephedrine takes a full minute or two.

I think the typical reasoning for the crashing patient is that a fast on, fast off med is desirable, that when paired with phenylephrine it covers a good range of vasoconstrictive vs cardioactive effects, and probably most of all that it tends to be familiar to us and immediately available outside the OR (if only in the code cart), whereas I've never seen an ephedrine stick within shouting distance.

 

[Carlos Danger]

I think the typical reasoning for the crashing patient is that a fast on, fast off med is desirable, that when paired with phenylephrine it covers a good range of vasoconstrictive vs cardioactive effects, and probably most of all that it tends to be familiar to us and immediately available outside the OR (if only in the code cart), whereas I've never seen an ephedrine stick within shouting distance.

Maybe. I've only used epi maybe a few dozen times outside of a cardiac arrest. But we deal with "crashing" patients daily in the OR, and ephedrine and neo (and vasopressin and calcium) is pretty much all we use.

Cardiac OR is a different story. They push all kinds of weird stuff. Milrinone, nitrates, norepi, everything.

 

[Brandon O]

Maybe. I've only used epi maybe a few dozen times outside of a cardiac arrest. But we deal with "crashing" patients daily in the OR, and ephedrine and neo (and vasopressin and calcium) is pretty much all we use.

Granted, but (as you say, outside of cardiac cases) I imagine this is mostly folks with okay hearts experiencing either a little more vasodilation than you planned (due to sedation) or perhaps getting a little behind on volume. In other settings there may be more of a need for a chronotrope/inotrope.

 

[TXmed]

Maybe. I've only used epi maybe a few dozen times outside of a cardiac arrest. But we deal with "crashing" patients daily in the OR, and ephedrine and neo (and vasopressin and calcium) is pretty much all we use.

Cardiac OR is a different story. They push all kinds of weird stuff. Milrinone, nitrates, norepi, everything.

Interesting sir, my base (and immediate area) have had a recent cluster of cardiac patients requiring RSI (late stage CHF, STEMI, balloon pump). and ive been working my hardest to find educational materials that can outline airway plans for these patients as i absolutely hate the "classic RSI" thought process. Maybe ephedrine push as apposed to an epi push can be better for these patients? possibly less stress on the heart itself?

 

[Carlos Danger]

Granted, but (as you say, outside of cardiac cases) I imagine this is mostly folks with okay hearts experiencing either a little more vasodilation than you planned (due to sedation) or perhaps getting a little behind on volume. In other settings there may be more of a need for a chronotrope/inotrope.

Yeah, generally the mechanism for hypotension that you see under GA is primarily vasodilation. But we do put plenty of sick people to sleep, and the cardiac effects of everything we do is in the forefront of our minds. This is why we generally try to a balanced and "gentle" response to hypotension.

Very broadly speaking, I think the worst thing you can do for a sick heart is to make it beat any faster than necessary. Tachycardia does much more to tip Mv02 balance in an undesirable direction than does increasing wall tension / afterload. At least without an echo to guide your pharmacotherapy precisely, I think a good general approach to hypotension in a sick person is a fairly balanced mix of volume replacement and alpha1 and beta1 stimulation, with a little more squeeze than cardiac stimulation. Which is exactly what you get from ephedrine.

When I think about the scenarios that EMS is going to be using pressors, I'm thinking more about post-RSI and sepsis-related hypotension than I am pump failure. In the post ROSC patient who has already gotten epi, just start a drip. Certainly there are times where more alpha is needed, but there are reasons why epi drips are rarely used in the ICU's. Those are the same reasons why epi boluses might not be the very best choice.

In actual practice, dilute epi boluses vs. ephedrine boluses is probably a wash in 99% of cases. And if it's all you've got, which is the often the case, then by all means use it. I was just making the point to TXmed that if you want to find prefilled syringes of epi and can't find any, just get your hands on ephedrine instead.

 

[E tank]

IME, it's important to recognize the purpose of an inopressor bolus beyond raising the blood pressure...a quick temporizing whack of neo,epi or whatever to offset a brief period of hypotension after a hypnotic and intubation is one thing and giving vasomotor tone/isotropic support post resus is another set of goals. Even then, epi vs ephedrine or even vasopressin should be followed by an infusion of something.

Bolus after bolus when a drip is called for is shadow boxing.... happens in the OR all the time .

 

[Carlos Danger]

IME, it's important to recognize the purpose of an inopressor bolus beyond raising the blood pressure...a quick temporizing whack of neo,epi or whatever to offset a brief period of hypotension after a hypnotic and intubation is one thing and giving vasomotor tone/isotropic support post resus is another set of goals. Even then, epi vs ephedrine or even vasopressin should be followed by an infusion of something.

Bolus after bolus when a drip is called for is shadow boxing.... happens in the OR all the time .

Nice to see another gas passer on here. . Nova1300 is an anesthesiologist who primarily does critical care and always shares really useful insight when he posts, and JWK is an AA and old paramedic who posts from time to time. I was a ghettomedic, then a flight paramedic and then a flight nurse up until 2012 when I started CRNA school.

 

[Carlos Danger]

Interesting sir, my base (and immediate area) have had a recent cluster of cardiac patients requiring RSI (late stage CHF, STEMI, balloon pump). and ive been working my hardest to find educational materials that can outline airway plans for these patients as i absolutely hate the "classic RSI" thought process. Maybe ephedrine push as apposed to an epi push can be better for these patients? possibly less stress on the heart itself?

There are a couple different ways to approach a sick cardiac patient who needs to be induced for intubation. I don't have a ton of experience with patients like this, but when I do go to the ICU to tube a sick patient with a big cardiac history I like to use a healthy but not huge dose of fentanyl (1-2 mcg/kg) and about a 1/4, maybe a half dose of etomidate. Those are just the drugs I'm familiar with, mostly from my HEMS days, honestly. I'll then cycle the BP as soon as I inflate the balloon, and I always have neo and ephedrine ready. Other folks prefer ketamine, but I haven't become a big fan of it yet as anything other than an opioid-sparing agent during GA. Some people give their pressors at the same time as their induction drugs, which is probably a good idea, but takes some more experience with this population than I have. Some folks just use really small doses of induction drugs and rely on the sympathetic response to the intubation, with the reasoning that all you really need in these cases is some amnesia.

Like I said before, I think ephedrine might be a better agent than epi for these purposes, but I don't have any data to back up that opinion. It's just how I see it, considering my understanding of the drugs and my experience with them.

I think for your purposes, just put your IVF under some pressure, go lighter on your induction agents, and be ready give a small dose of whatever pressor you have available is probably the way to go.

 

[TXmed]

I have a decent amount of experience with different kinds of dosing with ketamine for induction but none with etomidate (ive only used 0.3mg/kg), i guess with the popularity of ketamine the education on etomidate and different ways you can use the drug for induction have dwindled.