Historically, there has been concern regarding the administration of vasopressors through peripheral venous catheters (PVCs) due to the risk of extravasation, which can lead to tissue injury. Extravasation occurs when the medication leaks out of the blood vessel and infiltrates the surrounding tissue, causing damage. The fear of this complication may cause a delay in starting vasopressors, which are essential for managing hypotension and septic shock as early as possible.
In a 20-month study in an 18-bed medical intensive care unit, 734 patients received vasoactive medications (norepinephrine, dopamine, and phenylephrine) through peripheral intravenous access. Extravasation occurred in 2% of patients, but no tissue injury resulted after treatment with phentolamine and nitroglycerin paste. Thirteen percent of patients eventually needed central intravenous access. The study concluded that administering these medications via peripheral intravenous access is feasible and safe, with a low risk of complications. Thus, central venous access should not be considered an automatic requirement for vasoactive medication administration [1].
A systematic review assessed complications associated with vasopressor delivery via peripheral intravenous catheters (PiVCs) in adults. Seven studies with 1,382 patients were included. Noradrenaline was the most common agent administered. The mean infusion duration was 22 hours. Extravasation occurred in 3.4% of patients, but no instances of tissue necrosis or limb ischemia were reported. All extravasation events were managed conservatively or with vasodilatory medications. The findings suggest that vasopressor administration via PiVCs for limited durations and under close observation is relatively safe, with a low risk of major complications [2].
Additionally, using peripheral veins for vasopressor administration may decrease the time it takes to initiate vasopressor therapy in comparison to infusion via CVC. This is important because timely administration of vasopressors is crucial for stabilizing patients experiencing hypotension or shock.
Based on a 2022 article in Chest, the authors suggest that for patients starting on low-dose norepinephrine (such as less than 15 μg/min or less than 0.3 μg/kg/min), it is common to initiate the infusion through peripheral IV catheters and then evaluate if another type of catheter is needed. For patients who are likely to need norepinephrine for more than 24 to 48 hours, but are otherwise stable and require low doses, the authors typically transition to a midline catheter, drawing on their institutional expertise and experience. If a patient remains unstable or needs higher norepinephrine doses, additional vasopressors, or more ports for other infusions, the authors recommend promptly switching to a central venous catheter (CVC) for infusion [3].
The Surviving Sepsis Campaign guidelines have issued a weak recommendation to start vasopressors peripherally in order to restore mean arterial pressure (MAP) rather than delaying treatment until a CVC can be placed. This change in practice is aimed at ensuring that patients receive potentially life-saving treatment as quickly as possible, while still considering the potential risks associated with extravasation.
At our hospital, we adhere to a policy that limits the administration of norepinephrine through a peripheral line to a maximum dose of 0.1 mcg/kg/min and for a duration not exceeding 24 hours, unless the dose is being tapered. If these limits are surpassed, a central line is mandated for infusion. However, I am curious about the policy at your hospital regarding this matter!
What is the policy in your hospital regarding the administration of norepinephrine through peripheral lines, in terms of maximum dosage and duration
0.1 mcg/kg/min for no more than 24 hours
Up to 0.3 mcg/kg/min for no more than 24 hours
Up to 0.3 mcg/kg/min for no more than 72 hours
Other
.
REFERENCES:
1. 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 Sep;10(9):581-5. doi: 10.1002/jhm.2394. Epub 2015 May 26. PMID: 26014852.
2. Tian DH, Smyth C, Keijzers G, Macdonald SP, Peake S, Udy A, Delaney A. Safety of peripheral administration of vasopressor medications: A systematic review. Emerg Med Australas. 2020 Apr;32(2):220-227. doi: 10.1111/1742-6723.13406. Epub 2019 Nov 7. PMID: 31698544.
3. Teja B, Bosch NA, Walkey AJ. How We Escalate Vasopressor and Corticosteroid Therapy in Patients With Septic Shock. Chest. 2023 Mar;163(3):567-574. doi: 10.1016/j.chest.2022.09.019. Epub 2022 Sep 23. PMID: 36162481.
I find it strange that the associated image with this article saying PIVCs are ok for vasopressors administration (which are well known caustic/vesicant drugs), is highlighting the gravity of patient harm with visually demonstrating a large tissue sloughing injury, if associated to vasopressors or not.
While the administration of vasopressors peripherally has generated significant controversy, much of the reported incidences are quite low due to only those injuries were actually reported - how many tissue injuries were not reported? I believe the incidence of tissue-related injury from peripheral vasopressor administration is under-diagnosed and under-reported, regardless of the published findings.
Patient safety and harm reduction strategies from the associated injuries form vasopressors (or other caustic/vesicant medications) should be high on th…