Push Dose Pressors, They’re Not Just For Anesthesia Anymore!

I like preventing the complications of profound hypotension as much as anyone. Really, I do.

It’s why I suggest you focus so much on anticipating patient and provider needs during an emergency situation.

It’s why I suggest you put a norepinephrine drip in your pocket whenever hypotension can reasonably be predicted to happen. Maybe even (cringe!) a phenylephrine drip in some circumstances.

It’s also why I stress that simply having the drug in the room doesn’t do the patient any good – you need IV tubing and an IV pump too. The drip needs to be primed and the pump needs to be set.

These are all things I put in motion when assisting nurses and physicians at codes, rapid responses, intubation procedures, etc…

And so, when hypotension is identified as a problem that needs solving – all the nurse needs to do is connect the IV tubing to a port and press play on the IV pump (I’ve yet to meet a “Smart” pump even though I’ve met many pumps that claim to be smart).

Occasionally I don’t have the drip set up in time and ready to infuse. In this case, we’ll draw medication out of the IV bag into a syringe for IV push administration.

What should you give and how much? I’m so glad you asked! Because have I got a drug for you!

Introducing…Someolol™

Someolol™ was originally an herbal remedy developed in 1842 by Phineas Taylor Barnum. It was subsequently rebranded some time in the 20th century and extensively tested in young, healthy females experiencing hypotension after neuraxial anesthesia in obstetrics.

For use in critical care, Someolol™ has been studied extensively nowhere but you can find anecdotal evidence in many places such as here, here, and here. No direct patient outcomes data have been collected, but there is an encouraging trend indicating providers who use Someolol™ may sleep better at night.

Someolol™ might have side effects, or it might not. Also it may increase or decrease morbidity and mortality.

The active ingredient in Someolol™ changes depending on the lot, but don’t worry about that.

Because Someolol™ is not yet commercially available, it needs to be prepared at the beside. This is relatively easy since you only need to take a concentrated vasopressor and dilute it with 9 or 100 mL of Somediluent™ (sold separately). Then apply Somelabels™ (also sold separately) and you are ready to administer a dose.

Someolol™ is to be shaken, not stirred.

Because Someolol™ could contain any number of active ingredients, you can drive a bus through the recommended dose ranges. For this reason you are better off just giving some Someolol™ as soon as you can. Anywhere from 0.5 to 2 mL at a time is typically given.

Don’t forget to flush the IV with Someflushes™ (sold separately) so that the dose is actually administered.

The onset of Someolol™ is rapid. The duration is either 1, 2, or 5 minutes depending on the active ingredient and dose used.

The usual monitoring period for Someolol™ is every 5 to 15 minutes via cuff pressure. If you are giving a dose or active ingredient that only lasts 1 or 2 minutes, you should probably just give some more Someolol™.

Someolol™ requires a mostly dedicated assistant. The manufacturer recommends having one of the more highly trained persons in the room (physician or nurse) constantly tweak the amount of Someolol™ administered until the desired parameter is reached.

If the dedicated assistant becomes involved in another task and forgets about the 1, 2, or 5 minute duration of action, the makers of Someolol™ assume no responsibility for the patient outcome.

This was intended to be a parody.

Push dose pressors make sense to me if it will otherwise take too long to get an infusion started. But I prefer having the patient on a continuous infusion – even if it is for a short while.

The totality of the published data I have seen on push dose pressors has been in obstetrics to correct hypotension from neuraxial anesthesia. Those patients are in stark contrast to the ones I have used push dose vasopressors in – the septic, frail patient with hypotension after intubation.

The ideal agent to use based on duration of action is phenylephrine – but this is not the drug we want to start in patients with shock of essentially any origin.

Rather than turn the nurse or doctor into a smart pump, I make every effort to have an appropriate vasopressor drip available for these patients – even if it is just to be used transiently.

Do you have an opinion on using push dose vasopressors? Let me know in the comments below!

Credit to the idea behind Somelol™ belongs to this video from the late Doc John Hinds.

If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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