Push Dose Vasopressors

Patient Case  

  • The team gets a call that there is a 75 year old male that triggered a sepsis alert in route with EMS and is currently desaturating on 15 L of oxygen with decision made to intubate this patient  
  • Prior to intubation, the patient hasn’t responded to  a NS bolus infusion these are the patient’s vitals: 
  • Knowing that pre-intubation hypotension has been associated with peri-intubation cardiac arrest, which agent do you order? If it is not commercially available, how do you make it?  


 Phenylephrine (PE)  Epinephrine (EPI)  
Properties  A1 ++++   ↑ BP   B1  ±        ↔HR   B±     A1 +++      ↑ BP   B1 +++++   ↑ HR   B2 +++++  
Dose  100-200 mcg PRN Q 1-5 minute  10- 20 mcg PRN Q 1-5 minute  
Formulation  Premixed Syringe- 1000 mcg/10 ml  Not commercially available  
PK/PD  Onset: 1 minute   Duration: ~10-20 minutes  Onset: 1 minute   Duration: ~5-10 minutes  
Adverse Effects  Reflex bradycardia Hypertension  Tachycardia   Hypertension  
 Precautions  Bradycardia, heart block, heart failure, angina, acute MI  Tachycardia  
Compatibility  Compatible with NS, LR, D5  Compatible with NS, LR, D5  
Location in GHS  CPR, Trauma, Zone 2+3 Pyxis  1 mg/ml: CPR, Trauma, Zone 2+3 Pyxis  
Comments  Administer through a large bore peripheral IV; Low extravasation risk  Administer through a large bore peripheral IV; Low extravasation risk   

Making Epinephrine and Phenylephrine the “EASY WAY” Supplies: 10 ml of NS, Insulin syringe, epinephrine or phenylephrine vial, tape, pen Instructions:    Take an insulin syringe and draw up 0.1 ml of epinephrine 1 mg/ml or phenylephrine 10 mg/ml, dilute in 10 ml of NS, label epinephrine 10 mcg/ml (100 mcg total) or phenylephrine 100 mcg/ml (1000 mcg total) 
Making Epinephrine and Phenylephrine the Alternative Way   Epinephrine    Draw up 9 mL of normal saline into a 10 mL syringe (DO NOT use 10ml IV line “flush” syringes)  Into this syringe, draw up 1 mL of EPINEPHphrine 0.1 mg/mL (1 mg/10ml) from a cardiac syringe   Label syringe epinephrine 10 mcg/ml      Phenylephrine o Draw up 1 mL of phenylephrine from a 10 mg/mL vial into a 3 mL syringe o Inject this into a 100 mL bag of normal saline. Label bag; safely discard when finished  o Draw up 10 mL into a 10 mL syringe o Label syringe phenylephrine 100 mcg/ml         

Overview of Evidence  

Author, year   Design/ sample size  Intervention & Comparison  Outcome  
Rotando, 2019  Observational   ED/ICU   N=146  PE 100 mcg/ mL   or   Ephedrine 50 mg/10 mL  Most common indication = peri-intubation hypotension   Both agents associated with:   ↑ SBP by 26 mmHg   ↑ SBP by 26 mmHg   ↓ HR by 6 beats per minute   
Schwartz, 2016  Observational   ED   N=76  PE 100 mcg/ mL     (pre-filled syringe)     46.5%  patients were initiated on vasopressor drip ≤ 30 minutes;   mean MAP ↑ from 56.5 to 79.3 mmHg most common dose 100 mcg most common indication = peri-intubation hypotension  
Panchal, 2015  Observational   ED   N=119  PE 100 mcg/1 mL    PE given during the peri-intubation period: ↑ SBP by 20 mmHg, ↑ DBP by 10 mmHg, HR unchanged  
Doherty, 2012  RCT   OR   N=60  PE  IV push 120 mcg    (pre-filled syringe)   Vs    PE infusion @ 120 mcg/min  The infusion used more drug ( 1740 v 964  mcg)      Push dose pressor  had favorable impact of MAP compared to infusion   


  1. Micromedex [Electronic version].Greenwood Village, CO: Truven Health Analytics. Retrieved March 18, 2019, from http://www.micromedexsolutions.com/ 
  2. Scott Weingart. EMCrit Podcast 205 – Push-Dose Pressors Update. EMCrit Blog. Published on August 7, 2017. Accessed on March 19th 2019. Available at [https://emcrit.org/emcrit/push-dose-pressor-update/ ] 
  3. Holden D. Ann Emerg Med. 2018 Jan;71(1):83-92. 
  4. Panchal AR. J Emerg Med. 2015 Oct;49(4):488-94. 
  5. Rotando A. Am J Emerg Med. 2019 Mar;37(3):494-498. 
  6. Doherty A. Anesth Analg. 2012 Dec;115(6):1343-50. 
  7. Schwartz MB. Am J Emerg Med. 2016 Dec;34(12):2419-2422 

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