Preparation/administration of push-dose versus continuous infusion epinephrine and phenylephrine: A simulation

Hypotension is a common problem in the emergency department (ED) and intensive care unit (ICU) and can increase risk for poor outcomes. Many EDs/ICUs utilize epinephrine and phenylephrine to treat hypotension and these medications are most often administered as a continuous infusion (CI). Push-dose (PD) is the administration of small medication doses as intermittent intravenous pushes (IVPs). There is limited information comparing the time required to prepare and administer PD versus CI and errors have been reported when preparing and administering these medications at bedside. This simulation study sought to estimate preparation and administration times and preparation and errors with PD and CI epinephrine and phenylephrine when prepared by an ED/ICU pharmacist.

This crossover simulation study took place in a simulation center at an academic medical center and utilized a multi-venous intravenous training arm kit equip with an 18-gauge intravenous line, an extension tubing set, and a luer-lock adapter. The primary outcome was total preparation and administration time in seconds. The secondary outcome was major preparation and administration errors, defined as errors causing a five-fold or greater overdose.

In total, 16 pharmacists participated, including nine ED and seven ICU pharmacists. PD had faster total preparation and administration time and administration time, but not preparation time; PD showed an approximate 70 s decrease in total preparation and administration time versus CI. PD had more major preparation and administration errors and six PD preparations (18.8%, 6/32) had at least one major preparation and administration error. CI, on the other hand, had no major preparation and administration errors.

This simulation found faster total preparation and administration time with PD versus CI epinephrine and phenylephrine, but also found that PD had more major preparation and administration errors. Dilutional errors during medication preparation were the cause of 83.3% (5/6) of our overdoses.

This simulation study showed that ED/ICU pharmacists had faster median total preparation and administration times for PD epinephrine and phenylephrine versus CI, but PD also had more preparation and administration errors.