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The Push Dose Pressor Bridge

So we have pretty much all heard the craze on Push Dose Pressors (PDP) amongst the FOAMed chatter. Dr. Weingart took an old anesthesia trick used in the OR, and applied it to resuscitative medicine in the emergency room. In EMcrit episode 6 he discusses the expected lag time between ordering a pressor, receiving the infusion from pharmacy, and the drug actually getting into the patient. When MAP is critically low, this lag time can be detrimental to end organ perfusion. This is where PDP comes in handy. Every hospital has a code cart with cardiac epi at its disposal. A reduction of concentration to 100mcg in 100cc’s allows the much needed pressor support to bridge the lag time of pharmacy delivering your pressor infusion.

So what’s the issue?

The PDP trick was never suppose to replace an actual pressor infusion. It was an adjunct to buy time! If your patient is hypotensive prior to intubation... chances are they will be hypotensive after applying PPV. Now obviously you need to find the cause of the hypotension, but if it’s blood you need, one could argue that Levophed would be the better choice for short term pressor support and conversion of unstressed volume to stressed volume while you wait for your unit to arrive.

In the prehospital and critical care transport environment we have all these pressors at our finger tips. There is no need to wait on pharmacy! I have seen well polished teams mix Levophed infusions in a little less than a minute. What is an acceptable time frame from recognition of hypotension to pressor delivery? I don’t think we have enough data to give a clear answer. Sam Ireland in his “Epi Mixer” blog did a video comparing PDP vs Epi infusion. Both were completed in under two minutes. I believe this is an acceptable and realistic goal.

Shortly after Sam’s blog, Brian Behn sent us a video of him using a prefilled 1mg in 10cc cardiac Epi syringe. He wasted 9cc’s and then drew up 9cc’s of saline that was already infusing into the patient. This was extremely fast! Yet, this does waste 900mcg of Epi.

**One thing I didn’t mention in this podcast is the importance of clearly labeling your mixed infusion. The receiving facility could easily think your pressor is just saline if not labeled. I think we can all imagine how that fluid bolus would end.** PS. Thanks Cynthia Griffin for reminding me of this important point.

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