Can you give Vasopressors through a PIV?

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I looked back and couldn’t find a post about this topic in the last year or so but forgive me if it has already been posted. I have been following R.E.B.E.L. EM for a few months now  and I would recommend it to everyone who has the time and wants quick summaries on the latest EM literature.  They have short written summaries of papers including pros/cons of the study and what they feel are the most important take away points. It was founded by Salim Rezaie with Rob Rogers, Matt Astin and Anand Swaminatham serving as editors.

Occasionally they will have a “mythbuster” post looking at common myths in the ED and the most uptodate literature available on the topic. (their latest mythbust is on “safe” glucose levels before ED discharge but I digress)

 

Back in May they reviewed the safety of vasopressors through a PIV. The topic paper was titled “A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters”

What the review found was very interesting: of 318 events, 204 results in local tissue damage, 114 were only extravasation events and 7 events involved the use of a CVC (so clearly not completely safe). Interesting, of the 204 local tissue events 85.3% involved PIV distal to the antecubital fossa and 96.8% involved administration of >4hrs.

REBEL EM’s take away points were:

In critically ill patients, with hemodynamic instability, vasopressor infusion through a proximal PIV (antecubital fossa or external jugular vein), for <4hours of duration is unlikely to result in tissue injury and will reduce the time it takes to achieve hemodynamic stability.

What I feel like this means for us is simple: If you have a crashing, hypotensive patient who needs a pressor without a CVC but good proximal PIVs, start the pressor immediately, stabilize the patient as best you can, then take the time to properly place a CVC.

Continue to monitor the PIV until it can be switch to the CVC and stop the pressor immediately if there is any suspicion for local extravasation. I am sure this will make some people nervous but I think this is better then placing a “crash line” that is less then sterile which will expose an already ill patient to infection or other complications secondary to a hastily placed CVC.

I highly recommend read their review and how they came to this conclusion along with their other posts. I have included the link to this study at the bottom.

http://rebelem.com/mythbuster-administration-of-vasopressors-through-peripheral-intravenous-access/

24 thoughts on “Can you give Vasopressors through a PIV?”

  1. From pulmcrit: http://pulmccm.org/main/2015/critical-care-review/are-central-lines-really-needed-for-vasopressor-infusions/

    North Shore-Long Island Jewish Medical Center successfully treated over 730 patients with vasopressors through peripheral IVs, and published their results in the Journal of Hospital Medicine. More than 2/3 were given norepinephrine, considered to be a relatively dangerous vasoconstrictor in peripheral tissues, at up to 0.70 mcg/kg/min. They report no tissue injuries among the patients, even though extravasation of vasopressor into subcutaneous tissue occurred in 19 patients (2%, which were recognized and treated).

    Among other requirements, veins had to be measured by ultrasound and confirmed > 4 mm diameter. 18-20 gauge IVs had to be placed in the opposite arm from the blood pressure cuff, not in the hand, wrist, or antecubital fossa (where most peripheral IVs are placed). IV sites were maintained less than 72 hours and checked every 2 hours for signs of extravasation or absent blood return (these checks necessitated frequent brief interruptions in vasopressor infusions). For extravasation, local phentolamine injection and nitroglycerin paste to skin were applied.

    Only 13% of patients “failed” the peripheral IV protocol and required central line placement (e.g., for vasopressor use > 72 hours).

    Previously considered essential to high-quality care for almost all critically ill patients, central lines may in fact be unnecessary for most patients.

    — here is the abstract from the study—-

    J Hosp Med. 2015 Sep;10(9):581-5. doi: 10.1002/jhm.2394. Epub 2015 May 26.
    Safety of peripheral intravenous administration of vasoactive medication.
    Cardenas-Garcia J1, Schaub KF1, Belchikov YG2, Narasimhan M1, Koenig SJ1, Mayo PH1.
    Author information
    Abstract
    BACKGROUND:
    Central venous access is commonly performed to administer vasoactive medication. The administration of vasoactive medication via peripheral intravenous access is a potential method of reducing the need for central venous access. The aim of this study was to evaluate the safety of vasoactive medication administered through peripheral intravenous access.

    METHODS:
    Over a 20-month period starting in September 2012, we monitored the use of vasoactive medication via peripheral intravenous access in an 18-bed medical intensive care unit. Norepinephrine, dopamine, and phenylephrine were all approved for use through peripheral intravenous access.

    RESULTS:
    A total of 734 patients (age 72 ± 15 years, male/female 398/336, SAPS II score 75 ± 15) received vasoactive medication via peripheral intravenous access 783 times. Vasoactive medication used was norepinephrine (n = 506), dopamine (n = 101), and phenylephrine (n = 176). The duration of vasoactive medication via peripheral intravenous access was 49 ± 22 hours. Extravasation of the peripheral intravenous access during administration of vasoactive medication occurred in 19 patients (2%) without any tissue injury following treatment, with local phentolamine injection and application of local nitroglycerin paste. There were 95 patients (13%) receiving vasoactive medication through peripheral intravenous access who eventually required central intravenous access.

    CONCLUSIONS:
    Administration of norepinephrine, dopamine, or phenylephrine by peripheral intravenous access was feasible and safe in this single-center medical intensive care unit. Extravasation from the peripheral intravenous line was uncommon, and phentolamine with nitroglycerin paste were effective in preventing local ischemic injury. Clinicians should not regard the use of vasoactive medication is an automatic indication for central venous access.
    © 2015 Society of Hospital Medicine.

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  4. The only instance we now have seen girls avoid masculinization with
    this stack is by microdosing Winstrol. The addition of
    Winstrol on this stack will amplify general anabolism and lipolysis.

    Consequently, the results of Winstrol are usually extra pronounced
    than these of Anavar when taken alone, as evidenced by the suggestions and
    outcomes of our sufferers. However, we have observed Winstrol triggers extra
    severe opposed effects. The above dosages are tailor-made
    for newbies who have not used Anavar earlier than. These are only a
    few of the various natural options to Anavar
    which are out there available on the market today.
    I hear both guys and women say Masteron is a horrible AAS choice for girls.
    There is an inventory of different AAS that females are better off utilizing earlier
    than contemplating Masteron. Anavar, Equipoise, Primobolan, and
    even Dianabol are typically more tolerable for feminine
    users than Masteron. More than a couple of guys state that Masteron has caused the worst
    acne they’ve experienced with any steroid.
    If you’re a higher-weight person, Clenbuterol just isn’t what you should think about using.
    Clenbuterol is a well-liked anabolic compound as a end result of it’s thought to
    be quite much like the banned ephedrine in its results but less
    dangerous to use1. Nonetheless, that is fairly a misconception as
    a result of Clen also comes with its list of well being hazards, as well as no shortage of
    stories in the information of great sickness and even death after utilizing this substance.

    When you mix Sustanon 250 and Anavar, you’ll find a way to experience the advantages
    of both steroids. The Sustanon 250 will assist you to to achieve
    muscle mass and strength, whereas the Anavar will assist
    you to to burn fat and retain lean muscle mass. Anavar
    is a light anabolic steroid that is used for bulking and chopping purposes.
    Males customers normally stack Anavar with other anabolic steroids
    to get more practical outcomes.
    This will preserve peak serum testosterone ranges somewhat than experiencing fluctuations from infrequent dosing.
    Diligent customers will stick with moderate dosages,
    leading to significant fats loss and minimal unwanted aspect effects.
    Due to Anavar’s anabolic (muscle-building) effects, we
    find it typically doesn’t cause any weight reduction on the scales.
    Nevertheless, Anavar will cause significant amounts of fats loss, notably in cussed areas.
    This is why many bodybuilders can appear lean with low physique
    fat ranges yet possess a big waist, sometimes referred to as a
    steroid intestine. Like Anavar, it helps to advertise fats loss and enhance muscle definition.
    This contains deciding what to stack Winstrol with, the dose of each compound,
    where to position each in the cycle, and how long your cycle will be.
    A significantly advanced Winstrol cycle adds in Trenbolone
    – one of many hardest steroids to make use of and solely fitted to the most experienced
    customers. These two potent steroids mixed can create significant risks
    should you don’t know what you’re doing. These steroids will present rapid outcomes that may deliver a few
    very quick body transformation in a brief and sharp 6-week
    cycle. Males usually purpose for a low body fats percentage of underneath 4% with as much lean muscle as potential.
    But don’t be discouraged if you’re physique fat % sits round 12% – you’ll
    nonetheless see Winstrol’s results. Once the higher dose of these
    more extreme bodybuilders is stopped, virilization should subside –
    however, this isn’t guaranteed, particularly with extended
    and repeated use.
    That’s why Dianabol (Dbol) is so often used as a cycle kickstart stacked
    with Testosterone Cypionate. How far more you’ll have the ability to
    carry will tremendously rely upon what degree you’re
    already at, but breaking personal records should be expected.
    At the upper finish, you’ll find your self in a place to raise 40lbs, 50lbs, or much more than before.
    Testosterone Cypionate users will usually also experience wonderful muscle pumps.
    Clinical doses for TRT medical use will be at the lowest ranges
    – generally, as little as 100mg per week is prescribed.
    Medical professionals resolve on this and are individualized according to every male patient’s needs.

    Proviron is a potent androgen on paper, yet most girls can use it with minimal unwanted aspect effects at low to average doses.
    Because Proviron acts as an AI and may prevent the conversion of Testosterone to estrogen, males
    can endure from low estrogen symptoms if ranges aren’t well controlled.
    Low libido and fatigue are two potential signs that your estradiol ranges are low on Proviron, however blood testing is required to verify.

    With the cost and mildness of Anavar making it a steroid not worth taking by itself (unless
    for females), I’d not often be choosing between one or the other right here.
    I would combine them into a stack or fortunately
    use Anavar or Proviron as a hardening and drying compound to finish an extended cycle with different
    AAS. Some guys discover that those constructive temper effects begin becoming adverse as the weeks go on. Points with
    melancholy and irritability can develop, and that’s the other of
    what this steroid should be doing to you.

    Injectable steroids are not often hepatotoxic as a end result of they don’t pass by way of the liver like the highly
    poisonous oral steroids do. In instances where males are strongly predisposed to hair
    loss, shampoo like Nizoral, which topically blocks androgens directly on the
    scalp, can add another layer of mitigation in the path of this aspect impact.

    Some individuals will successfully use Nizoral 2% shampoo to treat steroid-induced zits.

    It essentially acts as a topical androgen blocker, although that’s not its main purpose (caution should at all
    times be taken when utilizing products off-label
    as irritation may occur). However it’s not simply testosterone itself that’s liable for any androgenic side effects
    you may develop. Largely, it’s the conversion of testosterone into DHT (dihydrotestosterone), which is an even more highly effective androgen that is the wrongdoer of a lot
    of the dreaded side effects in this category. On high of this,
    your genetics will largely decide if and how extreme these side
    effects could probably be.
    Anavar is very efficient in fat burning, significantly in stubborn areas of the body,
    such because the hips, thighs, and lower stomach. To shed weight, this steroid increases T3 ranges, a thyroid hormone recognized for its highly effective fats loss properties.
    Anavar (oxandrolone) is an anabolic steroid that simultaneously builds muscle and reduces fat mass.
    We have discovered Anavar to induce fewer toxic results in comparability with different
    anabolic steroids.
    Importantly,  the legality of steroids and
    peptides varies among countries and jurisdictions.
    We recommend checking legality in your nation before commencing your routine.

    The FDA has carefully examined the commercialization and utilization of particular
    peptides and steroids, expressing apprehensions about their safety and the
    absence of approval for numerous substances. Seek The Assistance Of a healthcare
    skilled or a educated coach who understands peptide usage.
    Look for well-known, established on-line retailers with positive critiques and verified
    customer feedback. Boards, bodybuilding communities, and social media can present suggestions.
    It’s necessary to remember that continual use of AAS can result in long-term joint points.

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  5. Gynecomastia, or the event of breasts in males, is a extensively known aspect impact
    of anabolic steroids. Gyno is amongst the severe cons of Anavar; it occurs
    when testosterone is converted into estrogen, resulting in breast
    tissue progress. Winstrol does not have a excessive androgenic rating; nevertheless, it
    does trigger notable androgenic effects in our experience.
    Therefore, zits, oily pores and skin, and hair loss are to
    be anticipated when combining it with trenbolone.

    Its bone-protective effects make it a promising adjunct therapy in osteoporosis
    management, reinforcing its functions past muscle-building (Johannsson,
    Medical Endocrinology). Winstrol is a superb chopping stack as Anavar does not have the 3Beta-hydroxy-5alpha-androstan-17-one (EpiAndro) that is nice for used to
    achieve strength whereas reducing physique fat.
    The unwanted facet effects of Anavar for ladies
    embrace potential masculinization, such as deepening of the voice and increased body hair.
    Keep Away From high doses and prolonged cycles to attenuate the risk of side effects when taking Anavar.

    Anavar’s low androgenic index makes these unwanted effects far much less frequent and is especially beneficial for people delicate to androgens, together with women. This profile makes Anavar one of the few anabolic steroids safely tolerated by female athletes when used responsibly (Basaria, Journal of Gerontology).

    Anavar advantages ladies by rising lean muscle mass, enhancing fats loss,
    and improving power without vital androgenic
    effects. Supporting muscle development and strength gains while on a calorie deficit may be robust.

    Fat loss is significant on Anavar, with research displaying a reasonable dose of 20 mg per day leading to four pounds of fats loss over the
    course of 12 weeks (4). Nonetheless, anecdotally, we now have observed further reductions in fat mass in our weightlifting patients.
    Anavar helps construct muscle, will increase power, and hastens recovery.
    It’s also used medically to help folks regain weight after surgical procedure or continual illness.
    Anavar’s enchantment to athletes lies in its significant influence on muscle growth,
    energy, and endurance. However, it’s detectable in drug exams, often for as
    a lot as 18 days, making its use risky in sports activities where
    testing is frequent, in accordance with the research
    published in PubMed [6].
    This compound was researched for its potential as an weight problems therapy, which provides us a good idea of what it’s been created to do.
    Stenabolic can be helpful for basic health goals because of its ability to boost endurance.

    Fairly excessive fat loss has been reported from Cardarine cycles;
    generally, up to forty lbs inside three months.
    Anavar by Hi-Tech Prescribed Drugs, rated at four.7 out of 5 stars, is a formidable complement in the muscle-building class.
    Its well-thought-out blend of natural steroidal anabolic
    brokers and supportive components work in live performance to supply vital features in muscle
    mass, power, and recovery. Regardless Of its higher price level and potential for
    gentle unwanted side effects in some individuals, the overwhelmingly constructive feedback from users underscores its efficacy and reliability.

    As such, Anavar is very beneficial for those looking for a potent, all-encompassing solution to speed up their muscle-building journey.

    Based on my intensive analysis Hi-Tech Pharmaceuticals Anavar stands out as a authorized and effective various to conventional Oxandrolone.

    I’ve found that its innovative formulation together with the Cyclosome™ supply system
    and punctiliously selected compounds offers impressive results for these looking for lean muscle positive aspects and fats loss.

    UGL HGH is significantly cheaper; however, it poses more
    risks due to hygiene issues or attainable contamination. With UGL merchandise, there’s additionally a chance of the
    product being diluted or counterfeited. The presence of Anavar is important on this
    cycle, not only from a fat-burning perspective but additionally to stop the physique from shifting right into
    a catabolic state. T3 can burn muscle tissue in addition to fat shops when taken without anabolic
    agents; thus, working T3 by itself is a potential disaster for a bodybuilder.
    Adding testosterone to this stack is optimal for customers wanting extra pronounced muscle
    features compared to taking HGH alone.
    Once More, these will develop quickly and severely in some
    folks, while others won’t have acne. This can be considered genetics, so if
    you’ve been acne-prone up to now, there’s a high
    probability you’ll develop this facet impact when utilizing Anavar.
    In Distinction To baldness, which is normally permanent until treated, zits must be
    lowered and clear once you cease using Anavar.
    We will focus on every little thing from Anavar dosage
    suggestions to expected outcomes. So, whether or not you’re a beginner or an experienced user, this weblog publish is for
    you. Evolve Biolabs urges customers to purchase merchandise solely from verified and reliable sources.

    Hair follicle exams, on the opposite hand, go that far and past compared to urinal and blood testing.

    To put this into perspective, a desk spoon of soy protein powder will
    solely weigh approx 18g. Lazar’s before/after (above) is
    a good example of an ‘anavar transformation’.
    I’m not saying Lazar 100% took anavar, however when you diet
    hard and work your butt off, these results are typical of someone taking anavar for eight weeks.

    This is known as virilization – when a girl starts to develop
    manly features. You can go onto Youtube and watch customers talk about
    their first expertise and listen to individuals debate about what they assume
    and the way much they’ve taken and for the way long.

    Post-cycle remedy (PCT) could additionally be necessary
    to restore normal testosterone ranges after discontinuing Anavar.
    Anavar, like other anabolic steroids, can probably impact cardiovascular well being.
    It might have an result on lipid profiles, resulting
    in unfavorable changes in levels of cholesterol. It is advisable to maintain a heart-healthy lifestyle, together with regular train, a
    balanced food plan, and monitoring lipid ranges when utilizing Anavar.
    Anavar, very like Dianabol is actually a really highly effective anabolic
    steroid, yet it does have the power to produce androgenic side effects.

    Extra users than not nonetheless suffer from oily skin, breakouts
    on the again and shoulders as properly as deepening of
    the voice and an increase in physique hair growth.

    References:

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  6. This contains the Usa, where oxandrolone is assessed as a Schedule III drug as a half of the Managed Substances Act (CSA).
    This means that simple possession of Anavar pills could
    result in up to a $250,000 nice and three years in prison. Nonetheless,
    it must be mentioned that any penalty this harsh is
    extremely unlikely.
    (6) Schroeder, E. T., Zheng, L., Ong, M. D., Martinez, C., Flores, C., Stewart, Y.,
    Azen, C., & Sattler, F. R. Results of androgen therapy on adipose tissue and metabolism in older men. The
    Journal of medical endocrinology and metabolism, 89(10), 4863–4872.
    (4) Schroeder, E. T., Zheng, L., Ong, M. D., Martinez, C., Flores,
    C., Stewart, Y., Azen, C., & Sattler, F. R.
    Thus, it is unlikely that somebody would be tested for steroids
    within the army, especially if they are quiet about their use.

    Masteron is an injectable steroid, and it’s the safer one to
    make use of for longer cycles. Despite the same advantages of both steroids, most girls will still wish to choose Anavar
    as a result of it’s a somewhat less potent steroid than Winstrol when it comes to unwanted aspect effects.

    Suitable health protocols must be adopted after the cycle to support liver, cardiovascular, and hormonal well being.
    Still, there is not a want to interact in any post-cycle therapy like men do.

    While Anavar has gentle natural testosterone
    suppression results, it rarely totally suppresses or even suppresses at half the natural
    levels. Hence, the decrease in SHBG is still highly beneficial regardless
    of your testosterone ranges when using this steroid.
    No, the sky-high anabolic score of Anavar doesn’t translate to
    it being a robust muscle builder.
    So many factors affect your results when using this (or any other) steroid.
    Having a PCT plan ready to go for the end of your Anavar cycle is a simple method of avoiding low testosterone.
    The dosing of Clen at all times needs to be
    tapered up to avoid outcomes plateauing as your physique adjusts.
    Masteron is thought to be a better mood enhancer than Anavar,
    however this effect can be very individual-dependent. Most Masteron users may also see a higher boost
    to the libido than is often experienced with Anavar.
    Anabolic steroids, such as Anavar, can increase the activity and sensitivity of oral anticoagulants (blood thinners).
    There can also be something to be stated about combining an Anavar
    dosage with caffeine. One study has demonstrated that simply 300mg of caffeine
    administered alongside Anavar increased subjects’ blood plasma
    levels of Anavar by 15 – 20x compared to baseline levels[10].

    Some ladies may want to go additional and add another two weeks to
    the cycle whereas increasing the dosage for these ultimate two weeks up
    to 20mg every day, however monitor for any potential unwanted effects.
    This isn’t a priority for girls who can proceed with an Anavar-only cycle on the beneficial 10mg day by day dose.
    Most cycles will utilize testosterone previous the 8-week Anavar cycle length, extending to 12
    weeks with testosterone earlier than beginning post-cycle remedy.

    Females working a primary Anavar cycle should start very low to judge
    unwanted effects. 5mg per day is understood to be well
    tolerated in medical use by many female sufferers.
    Beginning with a decrease dosage, similar to 20mg, allows your body to adapt and reduce the danger of opposed effects.
    As you progress and gauge your physique’s response, you possibly can steadily improve the dosage inside the really helpful
    range. Was initially developed within the Nineteen Sixties and was proven to have numerous therapeutic applications.
    It was used to treat these with lack of weight due to harm or illness.
    In the Eighties, this manufacturing has slowed significantly
    from stress from the FDA, and Anavar was taken off the
    cabinets in 1989.
    Athletes additionally appreciate Anavar because of
    the reality that it won’t produce a big buildup in mass.
    In some cases, added mass might be a hindrance relying on the sport, and in different instances, it’ll result in prying eyes that no athlete
    desires on them. When we further think about this steroid cannot lead
    to water retention, a possible burden to many athletes,
    Anavar rest as one of many top athletic decisions.
    While authentic testing revealed that there was no proof
    of liver disease in sufferers, this was primarily checked
    at a standard dosage and for relatively short durations of time.
    Another later study revealed high liver enzyme ranges,
    especially with larger doses and prolonged intake [7].
    If you’re located within the UK, US or other countries
    the place anavar’s unlawful – you have to very careful.

    Folks DO get sent to jail for taking steroids and if you’re doing dealings in the black market you’re operating the danger of going to jail and paying a
    hefty fantastic.
    Nevertheless, it is not likely to be used in pure
    bulking cycles because there’s a limit to only how excessive your dose of
    Anavar should be before health risks kick in. At the most basic stage,
    you possibly can count on to see some nice fat loss and a few average
    muscle positive aspects when you use Anavar.
    Anavar additionally increases nitrogen retention in the muscle17 – it is a
    prime operate of Anavar and is important in keeping the
    physique in an optimal anabolic state. The end
    result is retaining muscle mass whereas slicing
    fat by preventing the body from going into
    a catabolic state the place muscle tissue is
    misplaced, as is when nitrogen stability turns into negative18.
    Anavar is a fast-acting steroid derived from DHT (dihydrotestosterone)4 with a half-life of 8 to 10 hours.

    We can not say how much Anavar can suppress the body’s personal testosterone as
    a outcome of genetic predisposition, so it can prove troublesome.
    In my view, PCT is a time when testosterone restoration is
    paramount, and inducing extra suppression with a small, barely noticeable dose of
    Anavar appears poorly thought out. Concerning Anavar for women, virilization, or the development of male
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