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Safety of bolus-dose phenylephrine for hypotensive emergency department patients

Published:February 02, 2018DOI:https://doi.org/10.1016/j.ajem.2018.01.095

      Abstract

      Introduction

      Bolus-dose phenylephrine (BDPE) is routinely used to treat hypotension in the operating room. BDPE's fast onset of action and ability to be administered peripherally have prompted calls for its use in the Emergency Department (ED). There are few published data on the safety of BDPE use in the ED. Primary concerns include BDPE's potential to cause dangerous hypertension or reflex bradycardia. We hypothesize that BDPE is a safe short-term vasopressor choice for hypotensive ED patients.

      Methods

      We conducted a structured chart review for all patients who received BDPE from preloaded syringes over 42 months. We defined an adverse event (AE) as sBP > 180, dBP > 110, or HR < 50 within 30 min of receiving BDPE. We defined a serious adverse event (SAE) as an AE with pharmacologic intervention to correct vital sign abnormality. We also compared mean arterial pressure (MAP), sBP, and dBP pre/post BDPE administration to assess effectiveness. We used a two-sample t-test to assess for differences between the mean delta MAP after low versus high-dose BDPE.

      Results

      We identified 181 cases of ED use. 147 cases had complete pre/post vital signs. We identified 5 AEs and no SAEs. Three patients developed sBP > 180 mm Hg. The patients suffered no apparent harm. No patients had dBP > 110. Two patients developed bradycardia post-drug. In both cases, MAP improved despite bradycardia.

      Conclusions

      BDPE does not appear to cause reflex bradycardia or hypertension requiring intervention among hypotensive ED patients. The apparent safety of BDPE should be confirmed in prospective trials.

      Keywords

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      References

        • Jones A.E.
        • Yiannibas V.
        • Johnson C.
        • Kline J.A.
        Emergency department hypotension predicts sudden unexpected in-hospital mortality: a prospective cohort study.
        Chest. Oct 2006; 130: 941-946
        • Heffner A.C.
        • Swords D.
        • Kline J.A.
        • Jones A.E.
        The frequency and significance of postintubation hypotension during emergency airway management.
        J Crit Care. Aug 2012; 27: 417.e9-417.e13
        • Merz T.M.
        • Etter R.
        • Mende L.
        • et al.
        Risk assessment in the first fifteen minutes: a prospective cohort study of a simple physiological scoring system in the emergency department.
        Crit Care. 2011; 15: R25
        • Marchick M.R.
        • Kline J.A.
        • Jones A.E.
        The significance of non-sustained hypotension in emergency department patients with sepsis.
        Intensive Care Med. Jul 2009; 35: 1261-1264
        • Jones A.E.
        • Aborn L.S.
        • Kline J.A.
        Severity of emergency department hypotension predicts adverse hospital outcome.
        Shock Augusta Ga. Nov 2004; 22: 410-414
        • Kuhn J.C.
        • Hauge T.H.
        • Rosseland L.A.
        • et al.
        Hemodynamics of phenylephrine infusion versus lower extremity compression during spinal anesthesia for cesarean delivery: a randomized, double-blind, placebo-controlled study.
        Anesth Analg. Apr 2016; 122: 1120-1129
        • Mohta M.
        • Harisinghani P.
        • Seth A.K.
        • et al.
        Effect of different phenylephrine bolus doses for treatment of hypotension during spinal anaesthesia in patients undergoing elective caesarean section.
        Anaesth Intensive Care. Jan 2015; 43: 74-80
        • Allen T.K.
        • George R.B.
        • White W.D.
        • et al.
        A double-blind, placebo-controlled trial of four fixed rate infusion regimens of phenylephrine for hemodynamic support during spinal anesthesia for cesarean delivery.
        Anesth Analg. Nov 2010; 111: 1221-1229
        • Doherty A.
        • Ohashi Y.
        • Downey K.
        • et al.
        Phenylephrine infusion versus bolus regimens during cesarean delivery under spinal anesthesia: a double-blind randomized clinical trial to assess hemodynamic changes.
        Anesth Analg. Dec 2012; 115: 1343-1350
        • Lee H.-M.
        • Kim S.-H.
        • Hwang B.-Y.
        • et al.
        The effects of prophylactic bolus phenylephrine on hypotension during low-dose spinal anesthesia for cesarean section.
        Int J Obstet Anesth. Feb 2016; 25: 17-22
        • Keys A.
        • Violante A.
        The cardio-circulatory effects in man of neo-synephrine (1‑alpha‑hydroxy‑beta‑methylamino‑3‑hydroxy‑ethylbenzene hydrochloride).
        J Clin Invest. Jan 1942; 21: 1-12
      1. Vazculep (phenylephrine hydrochloride) label - FDA package insert.
        Eclat Pharmaceuticals, Chesterfield MOJune 2014
        • Cardenas-Garcia J.
        • Schaub K.F.
        • Belchikov Y.G.
        • et al.
        Safety of peripheral intravenous administration of vasoactive medication.
        J Hosp Med. Sep 2015; 10: 581-585
        • Delgado T.
        • Wolfe B.
        • Davis G.
        • et al.
        Safety of peripheral administration of phenylephrine in a neurologic intensive care unit: a pilot study.
        J Crit Care. Aug 2016; (Available from: http://www.sciencedirect.com/science/article/pii/S0883944116300284)
        • Panchal A.R.
        • Satyanarayan A.
        • Bahadir J.D.
        • et al.
        Efficacy of bolus-dose phenylephrine for peri-intubation hypotension.
        J Emerg Med. Oct 2015; 49: 488-494
        • Schwartz M.B.
        • Ferreira J.A.
        • Aaronson P.M.
        The impact of push-dose phenylephrine use on subsequent preload expansion in the ED setting.
        Am J Emerg Med. Dec 2016; 34: 2419-2422
        • Chobanian A.
        • Bakris G.
        • Black H.
        • et al.
        Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure.
        Hypertension. 2003; 42: 1206-1252
        • Lee A.
        • Ngan Kee W.D.
        • Gin T.
        A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery.
        Anesth Analg. Apr 2002; 94 (table of contents): 920-926
        • Stewart A.
        • Fernando R.
        • McDonald S.
        • et al.
        The dose-dependent effects of phenylephrine for elective cesarean delivery under spinal anesthesia.
        Anesth Analg. Nov 2010; 111: 1230-1237
        • Siddik-Sayyid S.M.
        • Taha S.K.
        • Kanazi G.E.
        • et al.
        A randomized controlled trial of variable rate phenylephrine infusion with rescue phenylephrine boluses versus rescue boluses alone on physician interventions during spinal anesthesia for elective cesarean delivery.
        Anesth Analg. Mar 2014; 118: 611-618
        • Dyer R.A.
        • Reed A.R.
        • Van Dyk D.
        • et al.
        Hemodynamic effects of ephedrine, phenylephrine, and the coadministration of phenylephrine with oxytocin during spinal anesthesia for elective cesarean delivery.
        Anesthesiology. Oct 2009; 111: 753-765
        • Flancbaum L.
        • Dick M.
        • Dasta J.
        • et al.
        A dose-response study of phenylephrine in critically ill, septic surgical patients.
        Eur J Clin Pharmacol. 1997; 51: 461-465
        • George R.B.
        • McKeen D.
        • Columb M.O.
        • et al.
        Up-down determination of the 90% effective dose of phenylephrine for the treatment of spinal anesthesia-induced hypotension in parturients undergoing cesarean delivery.
        Anesth Analg. Jan 1, 2010; 110: 154-158
        • Tanaka M.
        • Balki M.
        • Parkes R.K.
        • et al.
        ED95 of phenylephrine to prevent spinal-induced hypotension and/or nausea at elective cesarean delivery.
        Int J Obstet Anesth. Apr 2009; 18: 125-130
        • Sperry J.L.
        • Minei J.P.
        • Frankel H.L.
        • et al.
        Early use of vasopressors after injury: caution before constriction.
        J Trauma. Jan 2008; 64: 9-14