Push-Dose Norepinephrine in the Emergency Department

Acute hypotension is a frequent and high-risk presentation in the emergency department (ED) requiring rapid pharmacologic intervention. Push-dose vasopressors are commonly used as temporizing agents, though evidence describing push-dose norepinephrine (PDNE) use in the ED remains limited. While perioperative literature suggests favorable hemodynamic effects, real-world ED administration practices and short-term responses are not well characterized. This study aimed to describe the use, dosing practices, and short-term hemodynamic effects of PDNE in an academic ED.

We conducted a retrospective observational study of adult patients who received push-dose norepinephrine (PDNE) in the emergency department (ED) between March 2024 and August 2025. Exclusion criteria included PDNE administration during cardiac arrest and inadequate post-administration vital sign documentation. The primary outcome was short-term hemodynamic response, defined by changes in mean arterial pressure (MAP) following PDNE administration. Secondary outcomes included heart rate changes, dosing practices, and clinical indications for use. Data were summarized using descriptive statistics.

A total of 51 unique patients received 68 push-dose norepinephrine (PDNE) doses, of which 11 patients and corresponding doses were excluded, yielding a final cohort of 40 patients and 57 doses for analysis. Median doses of PDNE administered was 16-20 mcg (0.15-0.2mcg/kg). Among doses administered without concurrent vasopressor infusions, median mean arterial pressure increased from baseline 73 mmHg to 112 mmHg at 5 minutes and remained above 65 mmHg at 10 and 15 minutes in most cases. Heart rate demonstrated minimal changes over the same period, with mild decreases observed and no episodes of bradycardia. The most common indications for PDNE administration were peri-intubation and post cardiac arrest.

PDNE was commonly used for acute hypotension and was associated with rapid blood pressure improvement, minimal heart rate reduction, and no adverse events. These findings support the feasibility of PDNE as a short-term strategy in the ED and highlight the need for prospective studies to define optimal dosing, monitoring, and patient selection.