Evidence for the Epi-Spritzer (aka Push-Dose Pressor)

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Low-doses of IV epinephrine in unstable, hypotensive pediatric patients temporarily increased heart rate and mean arterial pressure (MAP).

Why does this matter?
The usual way epinephrine is used is as an infusion at 0.02–0.5 μg/kg/min for hypotension or a bolus 0.01mg/kg (max dose, 1 mg) for bradycardia or cardiac arrest.  Children with hypotension are often given low-dose epinephrine (the so called "push-dose pressor" or "epi-spritzer") to temporarily improve HR and BP.  But does this work?

The delicious "Epi-Spritzer"
This was a retrospective study of medical and surgical PICU patients with hypotension who were given low-dose single injection epinephrine, ≤ 5 µg/kg IV.  There were 63 episodes of hypotension treated as such in 19 patients, median age 9 years.  They found the mean dose given was 1.3 µg/kg.  Heart rate increased from 130 to 150 beats per minute after a median time of 1 minute and MAP increased from 51 to 75.  Doses < 1 µg/kg were not as effective as those which were 1 to 5 µg/kg.  There was no comment on important outcomes, such as mortality.  The authors concluded that this was an effective way to temporarily stabilize vital signs in pediatric patients until more definitive treatment could be given.  With a known duration of action for epinephrine of only 3-8 minutes, this doesn't buy much time.  The ED application is that while you are waiting for drips to come from the pharmacy, in very unstable children, low-dose epinephrine is an effective temporary way to increase HR and MAP.  This word of caution, be careful with epinephrine.  It is easy to make dosing mistakes and cause harm.  The low-dose is 1 microgram per kg.

Source
Low-Dose Epinephrine Boluses for Acute Hypotension in the PICU. Pediatr Crit Care Med. 2018 Jan 9. doi: 10.1097/PCC.0000000000001448. [Epub ahead of print]

Peer reviewed by Thomas Davis, MD.

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