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Myths in Emergency Medicine: Purveyors of Push-Dose Pressors Punks or Prophets?

Runde, Dan MD

doi: 10.1097/01.EEM.0000527803.39317.c8
Myths in Emergency Medicine

Dr. Rundeis the assistant residency director and an assistant professor of emergency medicine at the University of Iowa Hospitals and Clinics, where he serves as co-director for the associate fellowship in medical education. He creates content for and is a member of the editorial board forwww.TheNNT.com, and is a content contributor forwww.MDCalc.com. Follow him on Twitter @Runde_MC, and read his past articles at http://bit.ly/EMN-MythsinEM.

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Depending on your level of engagement with social media or how thoroughly you audit emergency medicine journals, you may not be aware of a recent kerfuffle/brouhaha/convulsion. The commotion is ostensibly about the use of bolus-dose vasopressors in the ED, but as I hope this discussion makes clear, the various parties are actually engaging in a debate that has raged, if not since Socrates was schooling Xenophon, then at least since emergency medicine began to emerge as a specialty.

One of the best teachers I ever had drilled into me the following maxim: anecdote≠data. The general idea is you can't generalize trends in medicine or clinical practice from one or two experiences. That said, when you begin to hear the same anecdotal experiences over and over, it's a foolish person who doesn't at least start to pay closer attention. Enter the idea of using push-dose pressors for the critically ill, hypotensive patient. I would wager that anyone who has worked with EM trainees in the past half-decade has had this topic raised on more than one occasion, not by their wizened critical care-boarded, EM colleague but by a fresh-faced intern who no doubt learned about it snapchatting on the Instagram while riding their fixed-gear bicycle into work.

It appears to be this experience, coupled with a sincere concern about best practices (in patient care and resident education) that prompted the authors Acquisto, et al., to fire the following warning shot.

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Medication Errors with Push Dose Pressors in the Emergency Department and Intensive Care Units

Acquisto NM, Bodkin RP, Johnstone C

Am J Emerg Med

2017 Jun 7; http://bit.ly/2z4zlYE

The article raised concern about the safety of push-dose pressors, citing several examples of medication errors that occurred at their institution and noting that their use may have occurred in lieu of standard resuscitative efforts (read: pressors before fluid boluses or blood products). They also correctly observed that not all hypotensive patients are created equal (i.e., hemorrhage vs. sepsis vs. pump issues), and seem to worry that push-dose pressors use may circumvent the thought processes and critical actions appropriate to these different patient populations.

All right-thinking individuals will probably agree that none of these points is terribly controversial, but the authors also have a bone to pick with what they see as the cause of this rampant uptick in ED push-dose pressor use: free open access medical education (FOAMed). They noted that the topic of push-dose pressors is often discussed online, and cited a particular EM:RAP episode as a potential instigator of the current craze. (Emergency Medicine: Reviews and Perspectives. The Doc in the Bay: Underutilizing Epi in Anaphylaxis, 2015;15[12]; http://bit.ly/2hEViGQ.)

Perhaps unsurprisingly, the suggestion that FOAMed might be creating practice patterns that put patients at risk engendered a vigorous response on behalf of clinicians and educators who believe in and contribute to these Socratically Sudsy endeavors.

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Response to: Medication Errors with Push Dose Pressors in the Emergency Department and Intensive Care Units

Awad NI, Mell HK, Swaminathan AK, Hayes BD

Am J Emerg Med

2017 Aug 2; http://bit.ly/2i8pDRU (Subscription required.)

These authors observed, correctly, that in each of the specific cases cited in the Acquisto article, poor communication was at the heart of each mistake. They also took issue with the authors' anecdote-based assertion that FOAMed is responsible for the increased use of push-dose pressors, and noted that we are not provided with any kind of denominator (i.e., how often push-dose pressors are used in the ED) so we have no way of knowing whether related medication errors are commonplace or statistically rare. The article closes with an appeal to lifelong learning and the need to critically appraise all potential sources of information, be they blog- or book-based. The authors asserted that EM:RAP≠FOAMed, a point that is 100 percent technically correct, but at the same time not really (thanks to the efforts of EMRA, many EM trainees have access to the podcast free of charge, and many of the contributors to EM:RAP are active FOAMed educators).

In response to this well-thought out rebuttal, Team Acquisto took the field once more, escalating the situation to the always-fun “Response to: Response to:.”

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Response to: Response to: Medication Errors with Push Dose Pressors in the ED and ICU

Acquisto NM, Bodkin RP, Johnstone C

Am J Emerg Med

2017 Aug 2; http://bit.ly/2gBMRMG

Here the authors acknowledged the lack of hard statistics for their assertions, but also refused to discount the evidence of their own “lying eyes (and ears),” saying that based on many discussions internally and on a national level, it's clear that FOAMed and EM:RAP are driving push-dose pressor adoption. They acknowledged that communication issues can, of course, contribute to medical errors, but made the point that adopting practices that haven't been well-studied and lack safe systems for their implementation increases the chances that mistakes will be made.

Using some verbal jujitsu, they reprised the point made in the initial rebuttal, that “a technique described in any medium...requires the same degree of critical assessment, training practice, and clear communication,” indicating that they think this type of critical assessment is sometimes lacking in the FOAMed world in general and on this topic in particular.

Who's right? In an answer that will make neither camp happy, I'd have to say both are. The standard of care evolves over time, and anyone not getting bled by barber surgeons should be grateful for that fact, but it's not always an orderly process. Many times we adapt too slowly, even in the face of overwhelming evidence (see: the glacial adoption of lytics for STEMI as a great example). Sometimes we move too fast (see: tight glycemic control in the critically ill). It's rare that we hit the perfect balance, but that doesn't mean we shouldn't try.

Proponents of FOAMed are often, unsurprisingly, early adopters, disruptors, and innovators. They sometimes advocate for practices that haven't been studied via RCT or published in a peer-reviewed journal. That doesn't mean those practices are wrong, and as many people have pointed out, our peer-reviewed literature is littered with practices we now know are ineffective or outright harmful (looking at you, prophylactic lidocaine for ACS patients).

What we have here in the case of push-dose pressors is an example of our field adapting to new educational modalities and a newly adopted technique in a way that should make us proud. We have identification and adoption of a new technique, a recognition that further study and a systems-based approach might be valuable and a buy-in from both sides to engage in a thoughtful debate that moves the ball forward. Take as exhibits 1 and 2, articles in press and published this summer in Annals.

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Safety Considerations and Guideline-Based Safe Use Recommendations for “Bolus-Dose” Vasopressors in the Emergency Department

Holden D, Ramich J, Timm E, Pauze D, Lesar T

Ann Emerg Med; in press

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Bolus-Dose Vasopressors in the Emergency Department: First, Do No Harm; Second, More Evidence Is Needed

Cole JB

Ann Emerg Med 2017 Jul 26; http://bit.ly/2ykN7JK

The first article is a thoughtful discussion of the potential risks of ED-based push-dose pressor use, but rather than throwing up their hands and saying it can't be done, the authors offered some guidance and potential solutions. Dr. Cole in the second piece made a strong case that the current state of the evidence for ED push-dose pressors is weak and should raise concerns, before noting that the history of EM is rife with similar concerns regarding our ability to use RSI drugs or perform procedural sedation with propofol.

These concerns, once raised, prompted studies that definitively demonstrated their safety and efficacy. Detractors of FOAMed might rightly point out that both of these articles advocate a more guarded approach, but it's also indisputable that it was FOAMed that drove their publication, which in turn helps drive our specialty forward. To the FOAMed aficionados and their sincere skeptics alike, cheers.

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