This is an em Pulse mini series. Push
dose pills with your hosts Sarah Made and
Julia Mc.
Welcome back to another episode of push dose
pearls. Our ongoing series of brief podcasts that
addresses the questions that we all have regarding
medications in our emergency department. And we are
back with Chris Adams, our Ed clinical pharmacist
at Uc Davis and our very own em
pulse pharmacist.
And today in our episode of push dose
pearls, we are going to talk about push
dose press.
It's about time I guess with that for
a title.
So Chris start us off, what exactly is
a push dose press.
So it's the idea of utilizing some kind
of vas
to provide a brief period of
hem
support for a patient? And when would you
actually use that? So this is an important
question.
A time period for the use of this
is when you're bridging a patient from
say, period of hypotension to an infusion. These
are very short acting agents vas. And so
if you're administering a push of this medication,
you're really only providing a transient period of
hem
support. And so the idea of vas depress
is to utilize them as a continuous infusion.
So realistically,
these medications are dangerous and in the wrong
hands, they can be potentially harmful to patients.
And so utilizing them as a continuous infusion
provides us a safety buffer, a nice way
to to administer it in a safe manner.
The other period where I think it would
be useful is in a temporary or transient
period of unstable hem
where a patient is likely to recover rapidly.
Sir, wouldn't you use push dose pressures.
So I think about it in, for example,
a case where maybe we've had a a
code a cardiac arrest, and we've gotten Ro,
and we are getting an Epi drip ready
and the, you know, heart rate or the
pull starts to weigh in a little bit.
And I think, ugh, this, you know, if
we can just get a little bit more
epi board, that would be helpful. And so
maybe it's a good time to use a
a push of Epi while we're bridging to
that epi drip. Yeah. Bridge seems like the
right term to use here.
When should you not use a push dose
compressor?
In a situation where a patient is gonna
need continued hem
support. In a scenario where a patient, like,
is likely like a septic patient is likely
to continue to be
unstable. Those patients need to continuous infusion. So
realistically, this only provides a short period of
time.
Otherwise, the provider, the nurse, whoever is is
administering those medications
is at bedside administering small doses of an
individual syringe over and over and over again.
So realistically, if you identify this patient's going
to have
continued hem
instability start a continuous infusion. What about a
peripheral line?
Peripheral lines are
just as good as a central line in
these very emergent scenarios. So I think it's
important to highlight here you certainly can use
peripheral lines. Obviously, with Vas depress, a central
line is preferred, but that's also not possible
in these emergent scenarios in a lot of
cases. So peripheral lines, perfectly good option in
these specific cases.
Okay. So which pressures can we push?
So the most common
pressures that are available as a push are
ph
as well as epinephrine. These medications already come
in a pre made syringe, so they're extremely
easy to push as a push dose press.
In addition, there is some utilization of norepinephrine
as a push dose pressure. However, that really
has not made its way into emergency medicine
practice more commonly that's practice. Practiced in an
Or r setting.
So some of the protocols or suggestions for
push dose pressures that I've seen have required
us to pull up a small amount and
diluted and then push it.
You're mentioning already coming in a prem made
syringe.
What is your approach
to push dose pressures as far as dose
and rate. Ph is easy. It's a a
medication in a syringe that is available to
be pushed in individual a doses. So there
is no need for
dilution of ph.
Epinephrine, however, comes in a 1 milligram syringe.
And therefore, each 0.1
ml
volume
contains a hundred micro of epinephrine.
That's a fairly large dose to be pushing
for each patient, especially pediatric patients, and that's
challenging.
For adults, a hundred micro
is
tolerable, but realistically, we should be aiming for
lower doses, say 10:20,
even 15 micro of epinephrine.
So in order to create that, the easiest
way is to take that 0.1
ml of an epinephrine syringe,
and then dilute that in,
9 ml. So you're making a total volume
of 10 ml with 10 micro
of epinephrine.
So again, you would take 1 ml of
that epinephrine syringe and then dilute it in
9 ml for a total of 10 ml
with 10 micro grams of epinephrine in 1
ml.
So you're not pushing it into the saline
bag. Exactly.
So that that the idea of utilizing Saline
bag as your d or even creating a,
quote, dirty epi bag. It has its place,
but at the same time, that's extremely difficult
to 1 tit trait. As well as potentially
dangerous depending on what... If you know what
you're doing and how much you need to
administer, as well as how do you continue
therapy when you transition to a known concentration
bag. You really don't know how much you
were giving in that 1 bag, and now
you're transitioning to another bag that that you
would just have no idea how to transition.
So what are the potential downsides of using
a push dose pressure? What kind of side
effects or effects should we'd be looking for?
Obviously, if you give too much, then we're
looking for a severe tachycardia, ta arrhythmia or
of,
hypertension. In those situations, obviously, that's not good
for patients, especially if they're suffering from,
cardiac disease.
However, most of the time, these are relatively
well tolerated even at larger doses.
The other significant side effect that is common
especially in these peripheral referral lines is that
you may have extrapolation
resulting in, a significant tissue damage around the
side of that extrapolation event.
So it sounds like you're suggesting giving, like,
10 to 20 micro, and you give it
over how long when you're pushing it. Generally,
these are rapid bolus. So you're giving 10
to 20 micro grams in just a matter
of seconds, 5 seconds. And then they only
last for roughly
2 to 5 minutes at most, and so
you're probably gonna be needing to give repeat
doses if a continued need persists.
And so the onset is pretty quick as
well. You should be seeing a rapid onset.
However, with that being said, we do need
to make sure that these are flush because
it's such a small volume that if you're
giving that dose, it may still be in
the line before it even reaches the patient,
So flush is really important in situation. That's
a good point. We have to worry about
that in kids all the time because our
doses are so small,
which actually takes me to my next question,
what about push dose pressures and kids? Certainly
have their place. However,
logistically,
much more challenging. We're talking about a
far smaller dose, far smaller volume, And so
we just have to be cognizant of that,
having a plan to create a dilution that
provides the appropriate dose is really challenging. And
so pediatric patients certainly present with a need
potentially for a push dose of a vas
pressure However, it's just a a hard situation
to make happen.
Yeah. It really is.
And I think that it's
not 1 that is best done in the
heat of battle, making that decision. You know,
I definitely
think It is helpful to come up with
a battle plan before you make those decisions
in the middle of the night, especially with
kids. How do you recommend
institutions
approach push dose pressures in the emergency department.
Simply have a plan and perhaps not just
a plan in your own mind, a written
down protocol
procedure or at least agreement among practicing
medical professionals So make sure that your pediatric
team knows exactly how this is gonna happen
where the medication is gonna come from what
syringe size it's gonna go into and what
the final concentration is going to be. If
you don't have prem made options available and
most institutions don't. That plan is gonna save
you the time,
to create whatever vas pressure you're going to
utilize as well as to hopefully ensure safety
associated with the use of that vas pressure.
Yeah. That makes a lot of sense to
me. And this is why I love having
an Ed pharmacist on hand.
Well, Therefore for.
Alright. That's it for now. Thanks again, Chris.
Really appreciate your insight.