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This is an em Pulse mini series. Push

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dose pills with your hosts Sarah Made and

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Julia Mc.

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Welcome back to another episode of push dose

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pearls. Our ongoing series of brief podcasts that

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addresses the questions that we all have regarding

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medications in our emergency department. And we are

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back with Chris Adams, our Ed clinical pharmacist

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at Uc Davis and our very own em

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pulse pharmacist.

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And today in our episode of push dose

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pearls, we are going to talk about push

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dose press.

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It's about time I guess with that for

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a title.

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So Chris start us off, what exactly is

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a push dose press.

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So it's the idea of utilizing some kind

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of vas

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to provide a brief period of

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hem

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support for a patient? And when would you

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actually use that? So this is an important

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question.

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A time period for the use of this

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is when you're bridging a patient from

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say, period of hypotension to an infusion. These

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are very short acting agents vas. And so

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if you're administering a push of this medication,

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you're really only providing a transient period of

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hem

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support. And so the idea of vas depress

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is to utilize them as a continuous infusion.

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So realistically,

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these medications are dangerous and in the wrong

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hands, they can be potentially harmful to patients.

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And so utilizing them as a continuous infusion

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provides us a safety buffer, a nice way

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to to administer it in a safe manner.

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The other period where I think it would

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be useful is in a temporary or transient

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period of unstable hem

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where a patient is likely to recover rapidly.

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Sir, wouldn't you use push dose pressures.

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So I think about it in, for example,

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a case where maybe we've had a a

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code a cardiac arrest, and we've gotten Ro,

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and we are getting an Epi drip ready

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and the, you know, heart rate or the

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pull starts to weigh in a little bit.

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And I think, ugh, this, you know, if

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we can just get a little bit more

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epi board, that would be helpful. And so

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maybe it's a good time to use a

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a push of Epi while we're bridging to

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that epi drip. Yeah. Bridge seems like the

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right term to use here.

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When should you not use a push dose

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compressor?

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In a situation where a patient is gonna

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need continued hem

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support. In a scenario where a patient, like,

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is likely like a septic patient is likely

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to continue to be

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unstable. Those patients need to continuous infusion. So

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realistically, this only provides a short period of

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time.

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Otherwise, the provider, the nurse, whoever is is

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administering those medications

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is at bedside administering small doses of an

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individual syringe over and over and over again.

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So realistically, if you identify this patient's going

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to have

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continued hem

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instability start a continuous infusion. What about a

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peripheral line?

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Peripheral lines are

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just as good as a central line in

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these very emergent scenarios. So I think it's

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important to highlight here you certainly can use

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peripheral lines. Obviously, with Vas depress, a central

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line is preferred, but that's also not possible

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in these emergent scenarios in a lot of

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cases. So peripheral lines, perfectly good option in

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these specific cases.

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Okay. So which pressures can we push?

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So the most common

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pressures that are available as a push are

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ph

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as well as epinephrine. These medications already come

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in a pre made syringe, so they're extremely

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easy to push as a push dose press.

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In addition, there is some utilization of norepinephrine

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as a push dose pressure. However, that really

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has not made its way into emergency medicine

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practice more commonly that's practice. Practiced in an

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Or r setting.

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So some of the protocols or suggestions for

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push dose pressures that I've seen have required

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us to pull up a small amount and

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diluted and then push it.

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You're mentioning already coming in a prem made

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syringe.

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What is your approach

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to push dose pressures as far as dose

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and rate. Ph is easy. It's a a

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medication in a syringe that is available to

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be pushed in individual a doses. So there

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is no need for

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dilution of ph.

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Epinephrine, however, comes in a 1 milligram syringe.

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And therefore, each 0.1

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ml

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volume

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contains a hundred micro of epinephrine.

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That's a fairly large dose to be pushing

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for each patient, especially pediatric patients, and that's

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challenging.

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For adults, a hundred micro

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is

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tolerable, but realistically, we should be aiming for

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lower doses, say 10:20,

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even 15 micro of epinephrine.

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So in order to create that, the easiest

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way is to take that 0.1

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ml of an epinephrine syringe,

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and then dilute that in,

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9 ml. So you're making a total volume

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of 10 ml with 10 micro

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of epinephrine.

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So again, you would take 1 ml of

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that epinephrine syringe and then dilute it in

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9 ml for a total of 10 ml

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with 10 micro grams of epinephrine in 1

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ml.

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So you're not pushing it into the saline

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bag. Exactly.

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So that that the idea of utilizing Saline

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bag as your d or even creating a,

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quote, dirty epi bag. It has its place,

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but at the same time, that's extremely difficult

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to 1 tit trait. As well as potentially

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dangerous depending on what... If you know what

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you're doing and how much you need to

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administer, as well as how do you continue

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therapy when you transition to a known concentration

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bag. You really don't know how much you

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were giving in that 1 bag, and now

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you're transitioning to another bag that that you

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would just have no idea how to transition.

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So what are the potential downsides of using

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a push dose pressure? What kind of side

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effects or effects should we'd be looking for?

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Obviously, if you give too much, then we're

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looking for a severe tachycardia, ta arrhythmia or

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of,

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hypertension. In those situations, obviously, that's not good

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for patients, especially if they're suffering from,

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cardiac disease.

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However, most of the time, these are relatively

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well tolerated even at larger doses.

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The other significant side effect that is common

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especially in these peripheral referral lines is that

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you may have extrapolation

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resulting in, a significant tissue damage around the

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side of that extrapolation event.

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So it sounds like you're suggesting giving, like,

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10 to 20 micro, and you give it

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over how long when you're pushing it. Generally,

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these are rapid bolus. So you're giving 10

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to 20 micro grams in just a matter

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of seconds, 5 seconds. And then they only

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last for roughly

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2 to 5 minutes at most, and so

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you're probably gonna be needing to give repeat

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doses if a continued need persists.

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And so the onset is pretty quick as

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well. You should be seeing a rapid onset.

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However, with that being said, we do need

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to make sure that these are flush because

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it's such a small volume that if you're

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giving that dose, it may still be in

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the line before it even reaches the patient,

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So flush is really important in situation. That's

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a good point. We have to worry about

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that in kids all the time because our

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doses are so small,

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which actually takes me to my next question,

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what about push dose pressures and kids? Certainly

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have their place. However,

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logistically,

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much more challenging. We're talking about a

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far smaller dose, far smaller volume, And so

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we just have to be cognizant of that,

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having a plan to create a dilution that

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provides the appropriate dose is really challenging. And

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so pediatric patients certainly present with a need

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potentially for a push dose of a vas

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pressure However, it's just a a hard situation

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to make happen.

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Yeah. It really is.

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And I think that it's

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not 1 that is best done in the

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heat of battle, making that decision. You know,

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I definitely

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think It is helpful to come up with

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a battle plan before you make those decisions

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in the middle of the night, especially with

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kids. How do you recommend

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institutions

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approach push dose pressures in the emergency department.

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Simply have a plan and perhaps not just

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a plan in your own mind, a written

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down protocol

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procedure or at least agreement among practicing

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medical professionals So make sure that your pediatric

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team knows exactly how this is gonna happen

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where the medication is gonna come from what

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syringe size it's gonna go into and what

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the final concentration is going to be. If

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you don't have prem made options available and

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most institutions don't. That plan is gonna save

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you the time,

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to create whatever vas pressure you're going to

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utilize as well as to hopefully ensure safety

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associated with the use of that vas pressure.

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Yeah. That makes a lot of sense to

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me. And this is why I love having

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an Ed pharmacist on hand.

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Well, Therefore for.

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Alright. That's it for now. Thanks again, Chris.

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Really appreciate your insight.