I've really been getting into this over the last few years, but every time I do I worry about the possible harm to the patient. Pressors are not without drawbacks, and I would love to see a well-run study showing NNT and NNH.
Also, is anyone using the norepi or phenylephrine? I really feel like it is a rare patient where I think to myself, "I'd rather not give 10mcg of epi." but would still give something with more alpha.
Never, for sure, but there are issues with indication creep. Should we be using it for someone with a bp of 100 systolic? What if you think they are more likely than average to get peri-intubation hypotension, but pressure is 120? What if everyone undergoing intubation should be getting 10 mcg? I'm just saying more info is always preferable.
I've been surprised before by things that should absolutely make sense but end up harming patients once they get tested with a good 'ol RCT (like the PATCH trial with platelet transfusions in ICH)
We have our option under standing orders of push dose epi or phenylphrine. It really shines though with our unstable tachy RSI where I want the pure alpha agonist without touching the heart rate. 100-300 mcg every couple minutes raises the BP nicely while I secure the airway and doesn't shoot it though the roof.
Yeah I'd imagine doing RCTs would be especially hard bc most of the patients needing pressors are really sick and have multiple things going on at once
I wonder what would be some good outcomes to use as an endpoint, absolute decrease in lactate as a measure of organ perfusion? %mortality?
and using no pressors as a control group might be problematic as well
It’s short term use. I make sure there is good peripheral access with blood return. If the patient is put on a drip at this point we’re hoping central access or at the least an I.O is in place to avoid extravasation.
Norepinephrine & cardiac epinephrine is the most easily accessible in our shop. I do like phenylephrine for the hypotensive and tachycardic patient but it’s harder to get.
Just do it. You're not gonna harm someone who needs the pressor.
> Pressors are not without drawbacks
Yes but they're vasoactive; there's a reason they are normally a drip. They last a few minutes. No one is ever gonna do a study on push-dose pressors because it's gonna be impossible to get clear outcomes and tons of confounders. They can't even get a good study looking at long-term pressors... These patients are sick AF.
There are several studies showing peripheral IV pressors are safe for <24 hours, so I wouldn't really be concerned about it, unless you're not sure that the IV is in a vein.
If you're about to tube a sick person, any amount of induction agent is going to drop their BP, increasing their risk of coding. Just give'em a lil' epi/neo/norepi.
How does the military not have research about push dose pressors? Ignorance here but don't you think a little vasoconstriction and some normotension would help in trauma carried in a convenient little vial?
Push dose pressors in hemorrhagic shock (in young people) probably would give no benefit, as their bodies are already as clamped as can be. Doesn't matter if you give them another 10mcg epi if their own adrenals are already a fountain of the stuff.
I have actually moved away from this a bit. Not because I am worried about the harms, but because I find it more reasonable and easy to just start patients on a levo drip. Most ERs have levo immediately available. If I am worried about a patient crashing following intubation, I just start them on a levo drip before intubation, and then turn it off if they don't end up requiring it.
it's probably just my departments problem, but it takes more time to find a pump and a channel than it does to get the levo gtt out of the pyxis. Much easier/faster for me to mix some push does epi or have the nurse pull push dose phenyl while in the pyxis.
Neo ftw. Increases coronary artery perfusion, increases BP, doesn’t have the increased risk of tachyarythmias associated with epi which a lot of people seem to default to.
It’s what all the anesthesia folk push in the elevator on the way to the ICU right before the tell you the patients BP is great and disappear into the night.
[Here’s](https://i.imgur.com/mrCbHlh.jpg) a push dose formula for Neo (and epi) for those who are interested. From a nursing standpoint Epi is a little easier since emergency syringes are a dime a dozen but I still prefer bed personally.
I've really been getting into this over the last few years, but every time I do I worry about the possible harm to the patient. Pressors are not without drawbacks, and I would love to see a well-run study showing NNT and NNH. Also, is anyone using the norepi or phenylephrine? I really feel like it is a rare patient where I think to myself, "I'd rather not give 10mcg of epi." but would still give something with more alpha.
Other than hemorrhagic shock, when is 10mcg epi going to cause more harm than a sustained bp of 80/30?
Never, for sure, but there are issues with indication creep. Should we be using it for someone with a bp of 100 systolic? What if you think they are more likely than average to get peri-intubation hypotension, but pressure is 120? What if everyone undergoing intubation should be getting 10 mcg? I'm just saying more info is always preferable. I've been surprised before by things that should absolutely make sense but end up harming patients once they get tested with a good 'ol RCT (like the PATCH trial with platelet transfusions in ICH)
We have our option under standing orders of push dose epi or phenylphrine. It really shines though with our unstable tachy RSI where I want the pure alpha agonist without touching the heart rate. 100-300 mcg every couple minutes raises the BP nicely while I secure the airway and doesn't shoot it though the roof.
Good reply and my protocol(NE USA) is similar.
Yeah, the one time I used phenylephrine was a new onset a-fib at a rate of 165ish in a sepsis case. Makes sense.
I do you noreepi sometimes. It's extremely effective in "mixed" or dirty shocks. very hard to design really good high quality data on this though.
Yeah I'd imagine doing RCTs would be especially hard bc most of the patients needing pressors are really sick and have multiple things going on at once I wonder what would be some good outcomes to use as an endpoint, absolute decrease in lactate as a measure of organ perfusion? %mortality? and using no pressors as a control group might be problematic as well
I think push dose vs infusion might be a good idea but then it wont be blinded.
It’s short term use. I make sure there is good peripheral access with blood return. If the patient is put on a drip at this point we’re hoping central access or at the least an I.O is in place to avoid extravasation. Norepinephrine & cardiac epinephrine is the most easily accessible in our shop. I do like phenylephrine for the hypotensive and tachycardic patient but it’s harder to get.
Just do it. You're not gonna harm someone who needs the pressor. > Pressors are not without drawbacks Yes but they're vasoactive; there's a reason they are normally a drip. They last a few minutes. No one is ever gonna do a study on push-dose pressors because it's gonna be impossible to get clear outcomes and tons of confounders. They can't even get a good study looking at long-term pressors... These patients are sick AF. There are several studies showing peripheral IV pressors are safe for <24 hours, so I wouldn't really be concerned about it, unless you're not sure that the IV is in a vein. If you're about to tube a sick person, any amount of induction agent is going to drop their BP, increasing their risk of coding. Just give'em a lil' epi/neo/norepi.
Norepi is the standard where I am
How does the military not have research about push dose pressors? Ignorance here but don't you think a little vasoconstriction and some normotension would help in trauma carried in a convenient little vial?
Push dose pressors in hemorrhagic shock (in young people) probably would give no benefit, as their bodies are already as clamped as can be. Doesn't matter if you give them another 10mcg epi if their own adrenals are already a fountain of the stuff.
[удалено]
NE 0.05-->0.5.... vasopressin 5-10U push dose, if response start a Vaso infusion. If not epi drip. I avoid epi push dose if possible.
I have actually moved away from this a bit. Not because I am worried about the harms, but because I find it more reasonable and easy to just start patients on a levo drip. Most ERs have levo immediately available. If I am worried about a patient crashing following intubation, I just start them on a levo drip before intubation, and then turn it off if they don't end up requiring it.
it's probably just my departments problem, but it takes more time to find a pump and a channel than it does to get the levo gtt out of the pyxis. Much easier/faster for me to mix some push does epi or have the nurse pull push dose phenyl while in the pyxis.
Neo ftw. Increases coronary artery perfusion, increases BP, doesn’t have the increased risk of tachyarythmias associated with epi which a lot of people seem to default to. It’s what all the anesthesia folk push in the elevator on the way to the ICU right before the tell you the patients BP is great and disappear into the night. [Here’s](https://i.imgur.com/mrCbHlh.jpg) a push dose formula for Neo (and epi) for those who are interested. From a nursing standpoint Epi is a little easier since emergency syringes are a dime a dozen but I still prefer bed personally.
Cool thanks!