Podcast 61 - DEBATE CLUB! "Push Dose Pressors"

So the other day I kinda mouthed off on FB... oops. (In my defense, I was about 14 hours in to my fasting period)

I will openly admit that when Dr. Weingart first coined the term "Push Dose Pressor," I drank the Kool Aid.. I remember pitching it to my organization and discussing the concept with the guys at my station. I think the early adoption was due to:

1. Cool Name

2. Easy To Mix

3. Weingart

4. Was better than pushing 500 mcg of cardiac epi when the patient starts circling the drain.

A few years later I had some opinions on whether the early adoption of this technique had preceded the evidence and properly implemented logistics in the EMS/HEMS environment. When I started to evaluate why this was beneficial in the ED, it became clear that these ED physicians were sometimes in the presence of a patient with critically low perfusion. Waiting on pharmacy to bring up a pressor took time that they didn't have. Left with nothing but the code cart easily accessible, they could utilize this technique to prevent the patient from dying while bridging to a drip when it arrived.

Makes sense...

When we compare the ED environment to ours, there is a stark contrast. All of our drugs are inches away from us, our pumps are mounted beside us, and we do not have to wait on anyone for anything. I began to think of the drive we all have to encourage early application of mechanical ventilation on intubated patients. This removes the subjectivity of a very critical intervention. So why don't we just start a drip?

I was sitting at the base with my partner Kevin Rixmann when we were discussing this. We were drilling on the logistics of how fast we could start a drip vs mix a push dose pressor (PDP). The cardiac epi syringe doesn't connect to the 10ml syringe without an adapter. The adapter is easy accessible, and it didn't take much time. What we realized though is that we still needed to mix a drip after the initial bumps of PDP. This sparked the "Bump & Drip" concept that was posted on FOAMfrat a few months ago. If we pushed levophed or epi into a 250 bag (like we were mixing a drip) and then just pulled a little off the bag, we could give the patient a "bump" of pressor while the other clinician sets up the pump.

This worked superb and it allowed us to maintain our normal concentrations we would use if starting a pressor infusion.

But there is no evidence to support push dose levophed?

There is actually no evidence for push dose epi (barring an editorial by Jon Cole and a bunch of Pharm D's discussing semantics). There is however an anesthesia article that looked at push dose levophed during spinal anesthesia.

Norepinephrine Intermittent Intravenous Boluses to Prevent Hypotension During Spinal Anesthesia for Cesarean Delivery: A Sequential Allocation Dose-Finding Study.

A few of my favorite pot stirrers showed up and didn't seem to be a big fan of my hyperbolic post.

So that's what we did.. I invited Michael Perlmutter (DitchDoc14) and Bryan Winchell (@bryanwinchell) to help re-convince me of why/when EMS should be utilizing around with PDP's.

Both of these dudes are extremely smart and I respect the hell outta them!

I also, messaged the man himself, Scott Weingart. I asked him if he thought PDP were applicable to EMS. Here is his reply:

"It is not the mixing, it is the pump. If you don't have pumps, then it should be push dose.

Vasopressor drips running by counting drips strikes me as a bad idea. It is indeed a bridge, a bridge to an infusion pump.It is time we start pushing for infusion pumps (they are small and pretty cheap if you buy syringe driver versions) on all medic buses"

It's important to play the role of devils advocate to re-prove a belief/concept that you may have merely just adopted empirically earlier in your journey as a clinician. That is why I have friends like Mike and Bryan.

I hope you enjoy this podcast!