Journal of Medical Toxicology

, Volume 15, Issue 4, pp 276–286 | Cite as

Human Errors and Adverse Hemodynamic Events Related to “Push Dose Pressors” in the Emergency Department

  • Jon B. ColeEmail author
  • Sarah K. Knack
  • Erin R. Karl
  • Gabriella B. Horton
  • Rajesh Satpathy
  • Brian E. Driver
Original Article



Though the use of small bolus doses of vasopressors, termed “push dose pressors,” has become common in emergency medicine, data examining this practice are scant. Push dose pressors frequently involve bedside dilution, which may result in errors and adverse events. The objective of this study was to assess for instances of human error and adverse hemodynamic events during push dose pressor use in the emergency department.


This was a structured chart and video review of all patients age ≥ 16 years undergoing resuscitation and receiving push dose pressors from a single center from January 2010 to November 2017. Push dose pressors were defined as intended intravenous boluses of phenylephrine (any dose) or epinephrine (≤ 100 mcg).


A total of 249 patients were analyzed. Median age was 60 years (range, 16–97), 58% were male, 49% survived to discharge. Median initial epinephrine dose was 20 mcg (n = 139, IQR 10–100, range 1–100); median phenylephrine dose was 100 mcg (n = 110, IQR 100–100, range 25–10,000). Adverse hemodynamic events occurred in 98 patients (39%); 30 in the phenylephrine group (27%; 95% CI, 19–36%), and 68 in the epinephrine group (50%; 95% CI, 41–58%). Human errors were observed in 47 patients (19%), including 7 patients (3%) experiencing dosing errors (all overdoses; range, 2.5- to 100-fold) and 43 patients (17%) with a documentation error. Only one dosing error occurred when a pharmacist was present.


Human errors and adverse hemodynamic events were common with the use of push dose pressors in the emergency department. Adverse hemodynamic events were more common than in previous studies. Future research should determine if push dose pressors improve outcomes and if so, how to safely implement them into practice.


Epinephrine Phenylephrine Push-dose pressors Free online open access medical education Medication safety 


Compliance with Ethical Standards

Conflicts of Interest


Supplementary material

13181_2019_716_MOESM1_ESM.docx (15 kb)
ESM 1 (DOCX 14 kb)


  1. 1.
    Jones AE, Yiannibas V, Johnson C, Kline JA. Emergency department hypotension predicts sudden unexpected in-hospital mortality: a prospective cohort study. Chest. 2006;130(4):941–6.CrossRefGoogle Scholar
  2. 2.
    Manley G, Knudson MM, Morabito D, Damron S, Erickson V, Pitts L. Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Arch Surg. 2001;136(10):1118–23.CrossRefGoogle Scholar
  3. 3.
    Brunauer A, Koköfer A, Bataar O, Gradwohl-Matis I, Dankl D, Dünser MW. The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients: a retrospective cohort study. Crit Care. 2014;18(6):719.CrossRefGoogle Scholar
  4. 4.
    Weigand S, Hedrick JN, Brady WJ. The use of bolus-dose vasopressors in the emergency department. Emerg Med. 2018;(March;50:72–6.CrossRefGoogle Scholar
  5. 5.
    Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med. 2015;2(2):131–2.CrossRefGoogle Scholar
  6. 6.
    Holden D, Ramich J, Timm E, Pauze D, Lesar T. Safety considerations and guideline-based safe use recommendations for “bolus-dose” vasopressors in the emergency department. Ann Emerg Med. 2018;71(1):83–92.CrossRefGoogle Scholar
  7. 7.
    Reiter PD, Roth J, Wathen B, LaVelle J, Ridall LA. Low-dose epinephrine boluses for acute hypotension in the PICU. Pediatr Crit Care Med. 2018;19(4):281–6.CrossRefGoogle Scholar
  8. 8.
    Ross CE, Asaro LA, Wypij D, Holland CC, Donnino MW, Kleinman ME. Physiologic response to pre-arrest bolus dilute epinephrine in the pediatric intensive care unit. Resuscitation. 2018;126:137–42.CrossRefGoogle Scholar
  9. 9.
    Kiser TH, Oldland AR, Fish DN. Stability of acetylcysteine solution repackaged in oral syringes and associated cost savings. Am J Health Syst Pharm. 2007;64(7):762–6.CrossRefGoogle Scholar
  10. 10.
    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;36(10):1802–6.CrossRefGoogle Scholar
  11. 11.
    Gottlieb M. Bolus dose of epinephrine for refractory post-arrest hypotension. CJEM. 2018;20(S2):S9-S13.Google Scholar
  12. 12.
    Cole JB. Bolus-dose vasopressors in the emergency department: first, do no harm; second, more evidence is needed. Ann Emerg Med. 2018;71(1):93–5.CrossRefGoogle Scholar
  13. 13.
    Mohta M, Harisinghani P, Sethi AK, Agarwal D. Effect of different phenylephrine bolus doses for treatment of hypotension during spinal anaesthesia in patients undergoing elective caesarean section. Anaesth Intensive Care. 2015;43(1):74–80.CrossRefGoogle Scholar
  14. 14.
    Schwartz MB, Ferreira JA, Aaronson PM. The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting. Am J Emerg Med. 2016;34(12):2419–22.CrossRefGoogle Scholar
  15. 15.
    Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of bolus-dose phenylephrine for Peri-intubation hypotension. J Emerg Med. 2015;49(4):488–94.CrossRefGoogle Scholar
  16. 16.
    Acquisto NM, Bodkin RP, Johnstone C. Medication errors with push dose pressors in the emergency department and intensive care units. Am J Emerg Med. 2017;35(12):1964–5.CrossRefGoogle Scholar
  17. 17.
    Edgar TA, Lee DS, Cousins DD. Experience with a national medication error reporting program. Am J Hosp Pharm. 1994;51(10):1335–8.PubMedGoogle Scholar
  18. 18.
    Farmer B, Smith SW. Introduction to special issue: at the precipice of quality health care: the role of the toxicologist in enhancing patient and medication safety : at the precipice of quality health care: the role of the toxicologist in enhancing patient and medication safety. Venue: 2014 North American Congress of Clinical Toxicology. ACMT pre-meeting symposium, New Orleans, LA. J Med Toxicol. 2015;11(2):165–6.CrossRefGoogle Scholar
  19. 19.
    American College of Medical Toxicology. Position statement: medical toxicologist participation in medication management and safety systems. J Med Toxicol. 2015;11(1):147–8.CrossRefGoogle Scholar
  20. 20.
    Hemphill RR. Medications and the culture of safety: conference title: at the precipice of quality health care: the role of the toxicologist in enhancing patient and medication safety venue ACMT pre-meeting symposium, 2014 North American Congress of Clinical Toxicology, New Orleans, LA. J Med Toxicol. 2015;11(2):253–6.CrossRefGoogle Scholar
  21. 21.
    Gilbert EH, Lowenstein SR, Koziol-McLain J, Barta DC, Steiner J. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27(3):305–8.CrossRefGoogle Scholar
  22. 22.
    Kaji AH, Schriger D, Green S. Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann Emerg Med. 2014;64(3):292–8.CrossRefGoogle Scholar
  23. 23.
    Chan T, Trueger NS, Roland D, Thoma B. Evidence-based medicine in the era of social media: scholarly engagement through participation and online interaction. CJEM. 2018;20(1):3–8.CrossRefGoogle Scholar
  24. 24.
    Lo A, Shappell E, Rosenberg H, Thoma B, Ahn J, Trueger NS, et al. Four strategies to find, evaluate, and engage with online resources in emergency medicine. CJEM. 2018;20(2):293–9.CrossRefGoogle Scholar
  25. 25.
    Weingart S. Push-dose pressors [Internet]. 2009 [cited 2018 Oct 9]; Available from: Accessed 9 Oct 2018.
  26. 26.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81.CrossRefGoogle Scholar
  27. 27.
    Raymond NJ, Nguyen M, Allmark S, Woods L, Peckler B. Modified sequential organ failure assessment sepsis score in an emergency department setting: retrospective assessment of prognostic value. Emerg Med Australas [Internet]. 2018;Available from;31:339–46. Scholar
  28. 28.
    Nawrocki PS, Poremba M, Lawner BJ. Push dose epinephrine use in the management of hypotension during critical care transport. Prehosp Emerg Care. 2019 Feb 26:1–8. [Epub ahead of print].
  29. 29.
    Wears R, Leape LL. Human error in emergency medicine. Ann Emerg Med. 1999;34(3):370–2.CrossRefGoogle Scholar
  30. 30.
    Awad NI, Mell HK, Swaminathan AK, Hayes BD. The authors respond: medication errors with push dose pressors in the emergency department and intensive care units. Am J Emerg Med. 2018;36(3):519–20.CrossRefGoogle Scholar
  31. 31.
    Rolfe S, Harper NJ. Ability of hospital doctors to calculate drug doses. BMJ. 1995;310(6988):1173–4.CrossRefGoogle Scholar
  32. 32.
    Nelson LS, Gordon PE, Simmons MD, Goldberg WL, Howland MA, Hoffman RS. The benefit of houseofficer education on proper medication dose calculation and ordering. Acad Emerg Med. 2000;7(11):1311–6.CrossRefGoogle Scholar
  33. 33.
    Hunziker S, Semmer NK, Tschan F, Schuetz P, Mueller B, Marsch S. Dynamics and association of different acute stress markers with performance during a simulated resuscitation. Resuscitation. 2012;83(5):572–8.CrossRefGoogle Scholar
  34. 34.
    Maslov MY, Wei AE, Pezone MJ, Edelman ER, Lovich MA. Vascular dilation, tachycardia, and increased inotropy occur sequentially with increasing epinephrine dose rate, plasma and myocardial concentrations, and cAMP. Heart Lung Circ. 2015;24(9):912–8.CrossRefGoogle Scholar
  35. 35.
    Hansen M, Eriksson C, Mah N, Meckler G, Guise J-M. Accuracy of prefilled “code cart” epinephrine syringes for direct administration of small doses. JAMA Pediatr. 2017;171(4):393–4.CrossRefGoogle Scholar
  36. 36.
    Farmer BM, Hayes BD, Rao R, Farrell N, Nelson L. The role of clinical pharmacists in the emergency department. J Med Toxicol. 2018;14(1):114–6.CrossRefGoogle Scholar
  37. 37.
    Roman C, Edwards G, Dooley M, Mitra B. Roles of the emergency medicine pharmacist: a systematic review. Am J Health Syst Pharm. 2018;75(11):796–806.CrossRefGoogle Scholar
  38. 38.
    Coralic Z. The dirty epi drip: IV epinephrine when you need it [Internet]. [cited 2018 Oct 10]; Available from: Accessed 10 Oct 2018.
  39. 39.
    Strayer RJ. Quick epinephrine drip [Internet]. Emergency medicine updates. 2009 [cited 2018 Oct 12]; Available from: Accessed 12 Oct 2018.
  40. 40.
    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;37(3):494–8.CrossRefGoogle Scholar
  41. 41.
    Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e9–13.CrossRefGoogle Scholar
  42. 42.
    Kaye W, Mancini ME, Truitt TL. When minutes count—the fallacy of accurate time documentation during in-hospital resuscitation. Resuscitation. 2005;65(3):285–90.CrossRefGoogle Scholar

Copyright information

© American College of Medical Toxicology 2019

Authors and Affiliations

  1. 1.Department of Emergency MedicineHennepin HealthcareMinneapolisUSA
  2. 2.Duke University School of MedicineDurhamUSA
  3. 3.University of Minnesota Medical SchoolMinneapolisUSA

Personalised recommendations