Human Errors and Adverse Hemodynamic Events Related to “Push Dose Pressors” in the Emergency Department
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.
KeywordsEpinephrine Phenylephrine Push-dose pressors Free online open access medical education Medication safety
Compliance with Ethical Standards
Conflicts of Interest
- 11.Gottlieb M. Bolus dose of epinephrine for refractory post-arrest hypotension. CJEM. 2018;20(S2):S9-S13.Google Scholar
- 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
- 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
- 25.Weingart S. Push-dose pressors [Internet]. 2009 [cited 2018 Oct 9]; Available from: https://emcrit.org/emcrit/bolus-dose-pressors/. Accessed 9 Oct 2018.
- 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. https://doi.org/10.1111/1742-6723.13154.CrossRefGoogle Scholar
- 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. https://doi.org/10.1080/10903127.2019.1588443. [Epub ahead of print].
- 38.Coralic Z. The dirty epi drip: IV epinephrine when you need it [Internet]. [cited 2018 Oct 10]; Available from: https://www.aliem.com/2013/06/dirtyepi/. Accessed 10 Oct 2018.
- 39.Strayer RJ. Quick epinephrine drip [Internet]. Emergency medicine updates. 2009 [cited 2018 Oct 12]; Available from: https://emupdates.com/quick-epi-drip/. Accessed 12 Oct 2018.