Push-Dose Norepinephrine in the Emergency Department

This session will provide a focused, practical review of push-dose vasopressors in emergency medicine, including pharmacology, dosing, preparation strategies, and monitoring. Institutional retrospective data will be used to illustrate real-world PDNE use and hemodynamic responses, while ongoing efforts to comparatively evaluate phenylephrine use will be discussed to contextualize vasopressor selection. Additionally, operational considerations including medication availability, compounding recipes, and common safety pitfalls will also be reviewed to support practical implementation in the ED. By combining didactic education with internal clinical data, this session aims to equip emergency medicine physicians and pharmacists with a structured framework for safe and effective push-dose vasopressor use and highlight opportunities for future development. Hypotension is a frequent and critical presentation in emergency departments (EDs), often requiring pharmacological intervention to maintain adequate perfusion to vital organs. In recent years, push-dose vasopressors have surfaced as a practical solution to transient hypotension while long-term vasopressor therapies are prepared. Phenylephrine and epinephrine have historically been used as push-dose pressors. Push-dose norepinephrine (PDNE) may offer a more favorable pharmacologic profile with its balanced alpha- and beta-adrenergic activity that improves blood pressure without reflex bradycardia, tachyarrhythmias, or reductions in cardiac output. In the anesthesia literature, PDNE has been studied extensively, demonstrating comparable or superior efficacy to phenylephrine with fewer heart rate reductions and less reactive hypertension. Despite growing interest in PDNE use within the ED, real-world data on its administration practices, safety, and short-term hemodynamic effects in this setting remain limited. At our institution, norepinephrine is available as premade 40 mcg/10 mL syringes, potentially reducing preparation time and facilitating rapid administration. Push-dose vasopressors are commonly utilized during peri-intubation hypotension, sedation-related hypotension, and undifferentiated shock, yet there remains significant variability in agent selection and dosing strategies. Emergency clinicians must balance rapid hemodynamic support with medication safety, particularly in unstable patients with limited physiologic reserve. While anesthesia literature provides important pharmacodynamic insight, ED patients differ substantially in acuity, comorbid conditions, and concurrent interventions, highlighting the need for ED-specific data to inform best practices. To better characterize PDNE use in the ED, we conducted a retrospective observational study at a tertiary academic ED evaluating dosing practices, indications for use, and short-term hemodynamic responses. Between March 2024 and August 2025, 51 unique patients received 68 PDNE doses. After exclusions for administration during cardiac arrest and inadequate vital sign documentation, 40 patients and 57 doses were included for analysis. Median PDNE doses ranged from 16–20 mcg (approximately 0.15–0.2 mcg/kg). Among doses administered without concurrent vasopressor infusions, median mean arterial pressure increased from baseline within five minutes and remained above 65 mmHg at 10 and 15 minutes in most cases. Heart rate changes were minimal, with mild decreases observed and no episodes of bradycardia. The most common indications for PDNE administration were peri-intubation hypotension and post–cardiac arrest hypotension.