You’re intubating a patient who is hemodynamically tenuous, or worse, was hemodynamically stable prior to induction. After administration of the sedative they become hypotensive. In many cases, the hypotension doesn’t present immediately because of the sympathetic stimulation of the laryngoscope. But once the tube is in and things settle down, the BP starts to drop. What do you do? This is almost always a transient problem. Do you need to start a drip? Anesthesiologists and an increasing number of EM providers use something called “push dose pressors.” Little boluses of vasopressor agents that can bolster your patient’s blood pressure to get them through a transient drop. In this article on Critical Care Now, Ruben Santiago covers the Pearls and Pitfalls with Push Dose Pressors. Although he approaches this from a ED perspective, the concepts are the same for transient hypotension associated with sedation in the ICU.

Propofol is a super common medication that we use for induction prior to intubation and for maintenance of sedation in the ICU. One of the big downsides of its use is the risk of hypotension. In this episode of the Elective Rotation podcast, Pharmacy Joe addresses the question “Can hypotension from propofol be predicted?” Although we can and do often use push-dose pressors to deal with this temporary hypotension from propofol and other similar agents in RSI scenarios, there are other situations where adequate sedation with propofol can lead to hypotension. In these situations, are the only answers to switch sedatives, tolerate inadequate sedation, or start vasopressor infusions? Nope. Give this episode a listen to discover more about predicting who will become hypotensive and how to prevent it (in some cases). Listen here.