The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting

The utilization of bolus-dose phenylephrine (PHE) has transitioned to the emergency department (ED) for the treatment of acutely hypotensive patients, despite a paucity of literature in this setting.

This was a single center retrospective chart review of the utilization of bolus-dosed PHE for acute hypotension in the ED at an academic non-forprofit hospital. The primary objective of this study is to report the frequency of patients that were initiated on a continuous vasopressor infusion (CVI) within 30 minutes after the first administration of bolus-dose PHE. Secondary objectives included an observational description of the impact of early preload expansion (fluids) on the initiation of CVIs in the setting of bolus-dose PHE in the ED.

Seventy-three patients met inclusion criteria for analysis. The primary outcome, 46.5% (n = 34) of patients were initiated on a CVI within 30 minutes following bolus-dose PHE. Initial preload expansion (30 mL/kg of IV fluids) was found to be significantly disproportionate with 34.2% appropriately fluid challenged vs 65.8% (P = .0048). In addition, a significant decrease in the number of PHE bolus doses were required [1.5 vs 2.3 (P = .01)] in the adequately IVF challenged group. For secondary endpoints, PHE was most commonly indicated for peri-intubation hypotension (n = 52, 71.2%). Significant adverse events were documented for 15 (20.5%) patients, with bradycardia (n = 7; 9.6%) as the most common adverse event.

Initial preload IVF expansion was found to be significantly disproportionate, and appears to be associated with an increase number of phenylephrine bolus doses in our study population.