Peripheral Vasopressors

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Tyler Jones
Critical Care Nurse Practitioner in Cleveland, Ohio. With a passion for teaching, POCUS and shock. I am a Husband to an amazing Wife/Nurse, dog father, world traveler and volunteer high school baseball coach.

The Pre-brief

Vasopressors are potent but a mainstay treatment in the ICU for shock patients. Loubani and Green first noted extravasation of vasopressors in the 1950’s . This extravasation was said to lead to tissue injuries such as limb ischemia, compartment syndrome and possible necrosis. Some contributing factors to necrosis at that time was difficulty obtaining IV access, smaller catheter size and the location of catheter placement. There have been extensive studies addressing the choice of vasopressors but very little information addressing the required IV routes for vasopressors.  Since vasopressors have been introduced, it has been taught, passed down, and assumed that, due to the complications listed above, central access is without a doubt required.

Hold the phone. Do you need that Central Line??

Central Venous catheters (CVCs) are not without their own risks. They include: pneumothorax, infection, bleeding, thrombosis, carotid artery injury, and the feared central-line-associated bloodstream infections (CLABSIs). McGee and colleagues noted that there is significant morbidity associated with central lines,  with the most frequent complication being arterial puncture that occurs in almost 15% of cases. However, now that ultrasound guidance has become the mainstay of visualization vs. landmark technique, complication rates have improved, especially in first past success.

Peripheral IV catheters (PIV’s) have a much lower risk for complications and are common. Not only is a PIV readily available, but they also are faster to obtain and with the recent surge in the ultrasound PIV placement they are more reliable now than ever. In most cases, PIVs over CVCs can help prevent delay of medication administration and reduce central line-associated bloodstream infections.

Bai et al. noted in the setting of sepsis and septic shock, (MAP < 65 mmHg or SBP < 90 mmHg) that for every one hour of delay in vasopressor administration there was an increase in mortality by 5.3%. 

As the nurse, be confident in that PIV that you placed, learn the steps to confirm placement with the US, maintain good blood return and integrity of the line. As the bedside warrior, if you can maintain the PIV you can save a central line complication and potentially further life-threatening infection or complications.

What is the Risk of Extravasation ?

Three of the most recent studies regarding peripheral vasopressors include Long Island Jewish Medical Center study, Emergency medicine Australia, and Pancaro et al.. These studies evaluated the safety of peripheral vasopressors in intensive care units, emergency departments, and the operating room. 

Long Island Jewish Medical Center study was an interdisciplinary collaboration that developed distinct protocols to conduct the trial. Their recommendations were the PIV had to be either a 20 or an 18 gauge, that the site had to be assessed every 2 hours, utilized upper extremity veins placed with US guidance, and a 72-hour maximum run time. What they observed was only a 2% risk in extravasation.

Emergency Medicine Australia and Medlej et al. showed that extravasation events at 3.4% and 5.4% were uncommon. These extravasation events did not have any significant tissue injury, necrosis, or serious complications noted.

Lastly, Pancaro et al. completed their study in the operating room setting and enrolled 14,000 patients to evaluate the events related to peripheral norepinephrine administration in sedation-induced hypotension. These European academic centers noted only five extravasation events or 0.035% of the population with no significant injuries noted. 

As you can see, the risk for severe tissue injury tends to be more minor extravasation events than events that are causing significant damage. As bedside nurses assessing your IV site frequently, completing the flush test to ensure your IV integrity and having a backup IV is crucial. If you feel that the current IV has lost blood return or is in question then immediately switch to your secondary IV, remove the old IV and replace it with a new one.  

This is the way!!

Common Protocol criteria for PIV Administration of Vasopressors

  •  I would advocate for PIV insertion with Ultrasound guidance (But please use longer catheter lengths i.e. >/=1.75 inches if possible) or make sure IV is confirmed with an US flush test.
    • Be cautious here, Rupp and colleagues noted that US guided PIV had an increased incidence of extravasation vs standard PIV placement practice. 
    • However, all hope is not lost and Pancaro et al., showed that the risk of extravasation decreased with each additional amount of catheter that resided in the vein. Go Big or…just go Big!
  • Avoid the hand/wrist area and keep below the AC
  • If using an inflatable BP cuff, place the cuff on the opposite extremity to limit pressure backlog
  • Either a 20 or an 18 gauge IV (Some facilities include 22 gauge, but I would recommend larger bore as long as they do not take up >45-50% of the vessel on US)
  • Check IV with peripheral vasopressors every 2 to 4 hours or appropriate time deemed by your facility
  • Make sure to have a “backup” or second IV to infuse through if the first becomes tenuous
  • Make sure your pharmacy has the antidotes on formulary (SQ phentolamine mesylate (Regitine) and nitro paste to the affected area)
  • Discuss a time limit (Recommended </= 72 hours) for peripheral vasopressors, but it does vary per organization.
  • Your facility will set forth the maximum allowable dose (norepinephrine typically 15-20 mcg/hr) to be infused through PIV before placing CVC.

Most commonly used peripheral vasopressors (Take a look here if you want to know more)

  1. Norepinephrine
  2. Phenylephrine 
  3. Epinephrine (bonus: given it’s alpha and beta activity, in extravasation events, it can partially be “its own antidote”)

The DeBrief:

– Peripheral vasopressors have been noted to have a low incidence of extravasation events and few  major complications

– If placing a US guided PIV for vasopressors use the longest length catheter for reduced chance of extravasation.

– Peripheral vasopressors could help reduce time to vasopressor administration and ultimately reduce mortality of the patient

– Save the patient adverse events from CVC placement and reduce the risk for CLABSIs 

– Have a protocol in place per your institution

– Be confident that peripheral vasopressors are safe!

References

  1. Bai X, Yu W, Ji W, et al. Early versus delayed administration of norepinephrine in patients with septic shock. Crit Care. 2014;18(5):532. Published 2014 Oct 3. doi:10.1186/s13054-014-0532-y

  2. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev. 2015;1(1):CD006962. Published 2015 Jan 9. doi:10.1002/14651858.CD006962.pub2

  3. Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015;10(9):581-585. doi:10.1002/jhm.2394

  4. Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care. 2015;30(3):653.e9-653.e6.53E17. doi:10.1016/j.jcrc.2015.01.014

  5. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123-1133. doi:10.1056/NEJMra011883

  6. Medlej K, Kazzi AA, El Hajj Chehade A, et al. Complications from Administration of Vasopressors Through Peripheral Venous Catheters: An Observational Study. J Emerg Med. 2018;54(1):47-53. doi:10.1016/j.jemermed.2017.09.007

     

  7. Pancaro C, Shah N, Pasma W, et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2020;131(4):1060-1065. doi:10.1213/ANE.0000000000004445

  8. Rupp JD, Ferre RM, Boyd JS, et al. Extravasation Risk Using Ultrasound-guided Peripheral Intravenous Catheters for Computed Tomography Contrast Administration. Acad Emerg Med. 2016;23(8):918-921. doi:10.1111/acem.13000

     

  9. Tian DH, Smyth C, Keijzers G, et al. Safety of peripheral administration of vasopressor medications: A systematic review. Emerg Med Australas. 2020;32(2):220-227. doi:10.1111/1742-6723.13406

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