Bolus dose pressors and inotropes have been used by the anesthesiologists for decades, but they have not penetrated into standard emergency medicine practice. I don’t know why. They are the perfect solution to short-lived hypotension, e.g. post-intubation or during sedation.
They also can act as a bridge to drip pressors while they are being mixed.
Our guidelines describe the use of push dose epinephrine in several instances, a well as the accompanying formulary. I think it is important to be familiar with the other push dose pressors as they may be used by practitioners in the ICU. Check out this pod cast and the accompanying notes by Dr Scott Weingarten.
Click Here for printable sheet with mixing instructions
POD Cast
http://blog.emcrit.org/?powerpress_pinw=76-podcast
Ephedrine
I don’t use this one much anymore, listen to the podcast to hear why.
Onset-Near Instant
Duration-1 hour
Mixing Instructions:
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe, draw up 1 ml of ephedrine from the vial (vial contains Ephedrine 50 mg/ml)
Now you have 10 mls of Ephedrine 5 mg/ml
Dose:
1-2 ml every 2-5 minutes (5-10 mg)
No extravasation worries!
Epinephrine
Do not give cardiac arrest doses (1 mg) to patients with a pulse
Has alpha and beta-1/2 effects so it is an inopressor
Onset-1 minute
Duration-5-10 minutes
Mixing Instructions:
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (amp contains Epinephrine 100 mcg/ml)
Now you have 10 mls of Epinephrine 10 mcg/ml
Dose:
0.5-2 ml every 2-5 minutes (5-20 mcg)
No extravasation worries!
Phenylephrine
Phenyl as a bolus dose is just the best! It is clean, quick, and never causes trouble.
It is pure alpha, so no intrinsic inotropy, but increases in heart perfusion can improve cardiac output.
Onset-1 minute
Duration- 20 minutes
Mixing Instructions:
Take a 3 ml syringe and draw up 1 ml of phenylephrine from the vial (vial contains phenylephrine 10 mg/ml)
Inject this into a 100 ml bag of NS
Now you have 100 mls of phenylephrine 100 mcg/ml
Draw up some into a syringe; each ml in the syringe is 100 mcg
Dose: 0.5-2 ml every 2-5 minutes (50-200 mcg)
No extravasation worries!
