Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department

Physiologic response to pre-arrest bolus dilute epinephrine in the pediatric intensive care unit

“…There was wide variability in dosing of BDE, as evidenced by a near 7-fold difference in index dose per kilogram within the interquartile range. In the adult literature, concerns for dosing errors have been raised surrounding the process of bedside dilution of the 100 mcg/mL epinephrine solution by clinicians who generally have less experience with drug dilution [7,8,18]. However, our institution stocks pre-mixed dilute epinephrine (10 mcg/mL), and therefore this issue would not have contributed to dosing variability.…”

“…Given that hypotension is the physiologic derangement most commonly identified prior to pediatric IHCA [4], its prevention and timely reversal is of high yield. The clinical practice of administering low-dose vasopressor boluses (commonly known as “push-dose”, “bolus-dose”, “dwindle-dose” or “spritzer” vasopressors) for acute hypotension has emerged, despite little published evidence describing its physiologic effects or impact on outcomes [5–8]. This practice likely originated from common obstetrical anesthesia practices for hypotension [9–11], but few studies have looked at the use of bolus-dose vasopressors in other settings [12–14].…”

High-Risk Airway Management in the Emergency Department. Part I: Diseases and Approaches

“…In addition, a significant rise in afterload may be detrimental in those with myocardial ischemia causing cardiogenic shock (35,38,39). Bolus or pushdose vasopressors risk dosing errors and lack a proven benefit over vasopressor infusions (35,40). A vasopressor infusion should be initiated early, with adequate volume resuscitation.…”

The Use of Bolus-Dose Vasopressors in the Emergency Department

“…These premixed formulations not only facilitate administration, but also reduce the chance of a preparation error that can result in incorrect dosing. [3][4][5] If pre-mixed formulations are not available, clinicians can readily prepare epinephrine and phenylephrine for PDP use.…”

“…[7][8][9] In addition, there are several articles in the literature that address safety concerns surrounding the use of PDP in the ED. 4,5 Panchal et al 10 investigated the use of phenylephrine in hypotensive patients undergoing RSI-assisted endotracheal intubation. The authors performed a 1-year retrospective review of hypotensive patients managed with endotracheal intubation for a range of clinical conditions that required clinical care intervention.…”