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Three Part Question

In [adults with acute hypotension in the emergency department (ED)], is [push dose pressor administration] an [effective and safe method to increase systolic and diastolic blood pressure]?

Clinical Scenario

A 74-year-old male with a history of diabetes and COPD presents via EMS in acute distress. EMS reports the patient was found somnolent and minimally responsive by a family member who came to check on him. He has a productive cough. Vital signs initially are significant for a rate of 122 BPM, a temperature of 39 degrees C, respiratory rate of 56, SpO2 of 89% and blood pressure 88/45. He has a GCS of 14. You suspect sepsis and begin your workup and treatment, including placing him on 6L nasal cannula. The patient is fluid resuscitated with 30 mL/kg of normal saline, cultures are drawn, and antibiotics are started. As the second liter is finishing, the patient becomes progressively less responsive and his SpO2 begins to drop. His blood pressure is now 82/38. As you prepare to intubate, you are concerned about his fluid-refractory hypotension in the peri-intubation period and consider a bloused dose of phenylephrine to bridge him to more definitive therapy.

Search Strategy

Medline 1966-07/21 using PubMed, Cochrane Library (2021), and Embase
[(hypotension [MESH]) AND (vasoconstrictor agents [MESH]) AND (exp push dose)].

Search Outcome

14 studies were identified; three studies addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Panchal AR et. al Oct 2015 USA	119 hypotensive patients requiring intubation from a single institution	Retrospective cohort analysis	The efficacy of peripherally administered bolus-dose phenylephrine for peri-intubation hypotension	Successful mean rise in SBP from 73 mm Hg to 93 mm Hg and DBP from 42 mm Hg to 52 mm Hg	Broad, inconsistent use without specific indications, regulation of dosage or administration; small number of patients actually received PDP (29/199); 70% (14/20) of patients receiving bolus dose phenylephrine were also treated with continuous intravenous infusion of vasopressors.
Rotando et. al. March 2019 USA	146 critically ill patients with administered PDPs, primarily in transient periods of hypotension	Retrospective cohort analysis	Efficacy of push-dose-pressors based on blood pressures pre- and post-PDP administration	The mean change in SBP was 26 mmHg, DBP was 13 mmHg, and HR was 6 beats per minute	Retrospective study with small sample size. Push dose pressor use is often used during high-stress or fast-paced situations resulting in incomplete or unclear documentation for PDP administrations. No evaluations of clinical outcomes, achievement of goal hemodynamics, or comparison to continuous infusion arm.
			Adverse effects	17 (11.6%) adverse events
Swenson et al. Oct 2018 USA	181 patients (144 medical and 37 trauma resuscitations)	Retrospective cohort study	Efficacy of push-dose pressors based on blood pressures pre- and post-PDP	Increases in MAPs proportionate to PDP doses, 200 mcg doses (MAP increase of 12) were more effective than doses 100 mcg doses (MAP increase of 4).	No protocol for choosing patient population; lack of matched control group; lack of isolated administration (eg without crystalloid, additional medications, blood products); abnd no clear change in clinical outcomes.
			Adverse events	No significant adverse events.

Comment(s)

Critically ill patients in the emergency department are hypotensive for a variety of reasons. It has become increasingly common to have push-dose-pressors (PDP), typically phenylephrine, on hand in case of sudden or anticipated hypotension, while a definitive intervention is pursued. This practice is common in operating rooms and extensive literature supports this practice. The emergency department is less a predictable environment with typically more tenuous patients. While the use of peripheral boluses of vasopressors like phenylephrine has proven to definitively raise both systolic and diastolic blood pressures without significant changes in a patient’s heart rate, there are no current guidelines, suggestions, or prospective clinical studies to direct this use or confirm its clinical efficacy. Though the retrospective cohort studies are promising, in order to establish evidence-based guidelines for its use, further research with larger, more diverse cohorts will be required.

Clinical Bottom Line

In adult patients with hypotension in the emergency department, push-dose-pressors effectively raise the mean arterial pressure for a brief period of time. Its use, including specific agent, dosage, and frequency of administration differs significantly between providers and institutions. Though the impact on long-term morbidity and mortality are unclear, limited studies indicate it is a safe and effective temporizing measure in a variety of clinical scenarios, from peri-intubation to sepsis.

References

1. Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension J Emerg Med 2015 Oct;49(4):488-94
2. Rotando A, Picard L, Delibert S, Chase K, Jones CMC, Acquisto NM Push dose pressors: Experience in critically ill patients outside of the operating room Am J Emerg Med 2019 Mar;37(3):494-498
3. Swenson K, Rankin S, Daconti L, Villarreal T, Langsjoen J, Braude D. Safety of bolus-dose phenylephrine for hypotensive emergency department patients Am J Emerg Med 2018 Oct;36(10):1802-1806