Push-Dose Pressors Outside the Operating Room: Systematic Review and Meta-Analysis of Observational Studies

Push-dose pressors (PDP) were mainly studied in operating room (OR) patients. Critically ill patients outside the OR present with different characteristics and logistical challenges. Available evidence in this population is limited, and the safety risk makes it a controversial therapy.

We performed a systematic review to evaluate the benefits and risks of using PDP in this population.

We included studies performed outside the OR, evaluating efficacy, safety and prognostic outcomes, as well as comparing different vasopressor strategies. We searched Pubmed for eligible studies. A random-effects meta-analysis (proportional for single-arm studies), reporting the mean, mean difference or risk ratio with 95% confidence intervals (CI) was performed. Risk of bias was assessed with the Newcastle-Ottawa Scale (NOS) scale.

Nineteen observational studies evaluating 5034 patients were included. 77.9% (95% CI [71.9-83.4]) of patients corrected hypotension after PDP, with a mean systolic blood pressure increase of 30 mm Hg (95%CI [24.7-35.9]). Adverse effects occurred in 14.4% (95% CI [7.8-22.5]) and serious adverse effects in 1.36% (95% CI [0.16-3.30]). Protocol use was associated with a non-significant tendency for lower risk of adverse effects, that became significant when considering only epinephrine. 69.5% (95% CI [59.3-78.9]) of PDP-treated patients needed a vasopressor infusion. Starting with PDP followed by infusion instead of infusion alone was associated with a non-significant lower survival at discharge (RR: 0.85, 95% CI [0.7-1.02]), that became significant after removing one influential study.

PDP is effective for transient hypotension correction in critical patients outside the OR, with a safety risk that could be reduced with protocol use. Clinical trials are needed to inform current practice.