Are you all tired of hearing about sepsis yet?  How about the fact that we apparently suck at sepsis?  However, I think we can all recognize when someone comes in with severe septic shock.  You know, the sick, hypotensive, altered patient with a source of infection.  With a low blood pressure, we just need to keep pushing more fluids right?  Just keep pushing them until they are in pulmonary edema.

Well, what could we possibly do to improve outcomes?  The longer they are hypotensive, the more end organ damage they are going to sustain, and the worse the outcomes.  I know that most of you all listen to EMCrit.  If you don’t, you should.  So while waiting for that central line to be placed by our intern (and we know that can take a while, j/k interns, I love you) and waiting for the levophed gtt to be started, we can be like Weingart and give some push dose pressors.  Not only could they be used for that septic patient needing a boost in BP, but can also be used for the peri- or post-intubation or sedation patient that becomes hypotensive.

Epi-It’s not ideal to give code dose epi to someone with a pulse.  Instead take a 10 mL syringe and fill it with 9 mL of NS.  Then draw up 1 mL of epi from the cardiac amp.  This gives you 10 mcg/mL of epi.  Now, give 0.5-2mL (5-20mcg) q1-5 min until improved BP.

Phenylephrine- Draw up 1 mL of phenyl from a vial that is 10 mg/mL and put in a 100 mL bag of NS.  This gives you 100mL of phenylephrine at the concentration of 100mcg/mL   Now you draw up 10mL into a syringe at push 0.5-2 mL (50-200mcg) q1-5 min.

And for your convenience, here is a link to a PDF from EmCrit with the instructions on how to mix these.  Take a pic, keep it on your phone.  While doing this, don’t forget patient safety.  Make sure you’re labeling your syringes when you mix up push dose pressors.  Avoiding medication errors is always plus.

Also, until you are comfortable doing this, make sure you are collaborating with your attending and the pharmacist if they are there at the time.

Finally, read this article on safety considerations in push dose pressors.

And for added fun, read all room9ER posts in Danny DeVito’s voice.  It makes everything better.