TVP as prerequisite for Push-Dose Pressors (?)

CWATT

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I was re-listening to EmCrit podcast #205 titled “Push-Dose Pressors Update” and around the 25min mark Dr. Weingart made the claim that ‘anyone using push-dose pressors should know how to initiate a Transvenous Pacer (TVP), otherwise they shouldn’t be using them’. My question is this — why does he consider TVP a prerequisite for push-dose pressors?

Obviouasly we aren’t about to do this intervention in the pre and inter-hospital environment (with possible exception to Kings County; they probably do craniotomies). Is the concern that clinicians might just keep repeat dosing in attempt to avoid bradycardia without treating the underlying problem (akin to thinking anticonvulsants like Midazolam are the treatment to seizures and overlook the underlying mechanism)? If so, this still doesn’t strike me as a contraindication.

Just curious what peoples’ thoughts are on the statement and possible rationale behind it.



Thanks,
- C


Link to EmCrit #205: https://emcrit.org/emcrit/push-dose-pressor-update/
 

Peak

ED/Prehospital Registered Nurse
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I disagree. First off TV pacing is a bandaid and does not replace EC or implanted pacers. Also with the wide advent of TC pacing I'm not convinced that TV holds all the precedence it used to.

I think that, more importantly, you need to look at the risks and benefits of treatment. We sometimes still use PDPs on our CHD kids even if they have EC wires in place which is far more effective than TV pacing.

I think that you also have to look at the purpose of treatment. Is it a bridge or therapeutic? I have a low threshold for EMS/ED to give PDPs where I have a much higher expectation from intensive care or anesthesia. Are we keeping the patient alive to definitive care or using it in lieu of definitive care?

In your analogy would I fault EMS for repeated indicated doses of verses (instead of hypersonic saline), of course not. Would I fault an ED, it probably depends on their size and acuity. Would I fault an ICU, absolutely.

All therapies have a place, we just need to follow the evidence and ensure that we give patients the best care we can provide.
 

VFlutter

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Only thing I can think of is paradoxical bradycardia sometime seen with Phenylephrine or potentially other PDPs. Abrupt increase in pressure creates a baro-receptor reflex. Not sure a TVP is necceary as it is usually short lived and should respond to Atropine or Iso.
 

Remi

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I think sometimes Weingart says things like that just because he wants to make it appear as though he thinks on a much higher level than most. I also think he forgets that not everyone works in a place as well equipped and resource-rich as Janus General.

“Push dose” pressors may be relatively new to Weingart and the rest of the EM and EMS community, but they have been used routinely in anesthesia for decades.

I gave some bumps of neo an hour ago, and there isn’t a TVP available for 40 miles.
 

RocketMedic

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Why in the Sam Hill would there be a TVP on an ambulance? Do they not know of TCP or that we’re not literally cardiologists in surgical suites?
 

E tank

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Never heard of this person, but this seems a pretty dogmatic (and pretty naive statement to make) I guess he's talking about the occasional reflex bradycardia from phenylepherine? It's a compensatory mechanism in response to acute rises in BP in order to mitigate potential end organ harm. The bradycardia is supposed to cause the pressure to level off or fall, so why would anyone ever pace in that circumstance? I can't imagine that's what he's suggestion, but then the statement makes no sense from the get go .
 

GMCmedic

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I dont listen to a ton of Emcrit, but I've never really heard much on there being specifically geared toward prehospital environments. I dont agree with the statement, but I doubt he had ambulances in mind when he said it.
 

CWATT

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... I doubt he had ambulances in mind when he said it.
I agree, but since I have Ephedrine, Epi, and Phenylephrine push-dose protocols within my scope of practice and no ability to initiate a TVP, I figured it would be worth questioning his motivation for making such a statement and explore how that might apply to me in a pre and inter-hospital environment.
 

Peak

ED/Prehospital Registered Nurse
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Even in referral centers TV pacing is not a common intervention.

Placing a TV pacer is pretty difficult. When you consider the anatomy the right IJ is your best shot, but floating into the RA and RV is no guarantee. It takes a skilled and experienced provider to place one, and I doubt most EM docs or even intensivists have placed one in the past 5 years.

We have a couple that sit in our trauma rooms in the ED. We have never placed one, rarely patients that go to cath lab may have one placed by cardiology if the patient is too tenuous to allow for a implanted pacer, but that is the only time I've ever seen one placed.

Our job in EM is to bridge to therapy be it a rural EMT basic or a tertiary referral center. Of the big cardiac hospitals in the city, adult or peds, I can't think any that are placing TV pacers in the ED.
 

E tank

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Even in referral centers TV pacing is not a common intervention.

Placing a TV pacer is pretty difficult. When you consider the anatomy the right IJ is your best shot, but floating into the RA and RV is no guarantee. It takes a skilled and experienced provider to place one, and I doubt most EM docs or even intensivists have placed one in the past 5 years.
We do it all the time for TAVR. It really isn't any big deal. You do need to know how to use an external pacemaker. Way easier than passing a PA catheter. Still, I have no idea what that guy is talking about.
 

Peak

ED/Prehospital Registered Nurse
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We do it all the time for TAVR. It really isn't any big deal. You do need to know how to use an external pacemaker. Way easier than passing a PA catheter. Still, I have no idea what that guy is talking about.
Correct, which is in the cath lab being placed by an interventional cardiologist.

I utilize epicardial pacing wires frequently so I'm plenty familiar with external pacing. I still don't think that it is very relevant for pre-hospital or ED care.
 
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