Critical Care, Improving Outcomes, Mythbusting

FOAMed: embracing the skeptics, push dose edition.

Embrace the skeptics. Seek them out. They’re actually your greatest allies.  Even when they express concerns over FOAM’s beloved push-dose pressors.

This paper reviews three cases of push dose pressor usage at their institution over an unnamed time period.

1) A post-op patient (“with known blood loss”) with hypotension in transport (no BP or MAP measurements given), and rather than optimize the slurry of midazolam, fentanyl, hydromorphone the patient was currently receiving, push-dose phenylephrine was utilized.  Except that 50 mg rather than 50 mcg was given, and propofol was then given to treat the resultant hypertension.  Now, they also suggest fluid boluses and blood, but since it was in transport… I dont necessarily think push dose was wrong, and I’m not sure where they would have gotten blood from since they were in transit, but yes, the providers certainly could have used phenylephrine concomitantly with toning back on the sedation package.

Take on case one: Tough case. You’re in transport, so options are limited.  Good thought, room for improvement.

2) A post-laminectomy patient who was receiving a norepinephrine infusion developed Afib RVR and was treatment with diltiazem IV boluses followed by continuous infusion. The patient developed asymptomatic hypotension (again, no BP or MAP measurements given) and push dose phenylephrine was given.  Unfortunately 1000 mcg was given rather than 100mcg of phenylephrine.  All while norepinephrine was still at the bedside, waiting to be restarted & titrated.

Take on case two: Dont get ahead of yourself, you’ve likely got more time than you think. Do the basics well.  Slow is smooth and smooth is fast. 

3) A hypotensive patient with angioedema who had epinephrine doses of 100 mcg, 300 mcg, 500 mcg and 1mg all intravenously (!), rather than the intended 5-20mcg.  The authors mention that the patient did not get IM epinephrine.  Being in a situation that demands to push 4 rounds of IV epinephrine must be a sticky one; I’m sure tensions were running high in the resuscitation bay.

Take on case 3: This was probably a pants-crapping case to be involved in.  Things probably could be done in tandem (IM epi while prepping IV).  Again, slow is smooth and smooth is fast.  You also fight the way you train.  I’m sure this was a nerve-racking case to be involved in.

The authors readily admit that they cherry pick cases- and in an email to the author, these cases came from anesthesia, EM, and critical care providers – attendings, fellows, and residents.  Also, in their paper they state, “we feel the time taken to manipulate these concentrations to provide small doses of vasopressor actually take the same amount of time as admixing and initiating continuous infusion vasopressor. “

But… Could you do that in transport?  What about facilities where norepinephrine has to come from pharmacy?

I *partially* agree with the author’s call for a more thought out process, and I think that this can be a call for more appropriate training (mentally, simulations, etc) prior to implementation.  Using push-dose pressors without being able to pull up how to mix and give them is akin to saying “I heard it on a podcast” without digging into the data yourself.  Perhaps maybe premixed vials handy are not the worst idea, hey, maybe we can get a push dose pressors dispenser akin to a fast food restaurant straw dispenser!  I do not agree with completely giving up pushing the boundaries and settling for “par for the course” when there is potential to do better.  Joe Bellezzo managed to do everything wrong on his first ECMO cannulation, but it did not stop the group from refining their approach and pushing the envelop to improve the next patient’s care.

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