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.