UMEM Educational Pearls

Title: Human errors involving "push dose pressors"

Keywords: push dose pressor, phenylephrine, epinephrine, human error (PubMed Search)

Posted: 7/11/2019 by Hong Kim, MD
Click here to contact Hong Kim, MD

“Push dose pressors” – administration of small doses of vasopressors in the emergency room has become a common practice. A recently published study investigated the incidence of human error and adverse hemodynamic events.

Push dose pressors were defined as:

Phenylephrine (any dose)
Epinephrine (<= 100 mcg)

Adverse hemodynamic event was defined as:

Extreme tachycardia (HR > 140 bmp)
New bradycardia (HR < 60 bmp)
Hypertension (SBP > 180 mmHg)
Ventricular tachycardia

249 out of 1522 patients were identified and analyzed from Jan 2010 to November 2017

median initial epinephrine dose (20 mcg; IQR: 10-100; range 1-100)
- recieved more than one dose: 78 (57%)
median initial phenylephrine dose (100 mcg; IQR: 100-100; range 25 to 10,000)
- received more than one dose: 62 (56%)

Adverse event

Phenylephrine group (n=110): 30 (27%; 95% CI: 19-36%)
Epinephrine group (n=139): 68 (50%; 95% CI: 41-58%)

Errors

Human error: 47 (19%) - similar proportion of human error between two agents.
Dosing error: 7 (3%; 2.5 to 100-fold)
Documentation error: 43 (17%)
Only one dosing error occurred when a pharmacist was present

Conclusion

Human errors and adverse hemodynamic event were common when “push dose pressors” were administered.
Consultation with a pharmacist can/may reduce dosing error.

References

Cole JB et al. human errors and adverse hemodynamic events related to "push dose pressors" in the emergency department. J Med Toxicol. 2019 Jul 3. doi: 10.1007/s13181-019-00716-z. [Epub ahead of print]