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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/
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.