By Kathryn Radigan, MD, MSc
Assistant Professor, Pulmonary Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL
Dr. Radigan reports no financial relationships relevant to this field of study.
SYNOPSIS: Administration of vasoactive medications by peripheral intravenous access is safe and feasible in critically ill, hypotensive patients.
SOURCE: Cardenas-Garcia J, et al. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med 2015 May 26 [Epub ahead of print].
Vasoactive medications (VMs) are most commonly administered through central venous catheters (CVCs). Cardenas-Garcia et al sought to evaluate the safety of administering VM through peripheral intravenous (PIV) access. In this single-center, single-arm, consecutive-patient study conducted between September 2012 and June 2014, 734 patients received norepinephrine, dopamine, or phenylephrine through PIV access 783 times. The duration of administration through the PIV was 49 ± 22 hours. Prior to study enrollment, there was an established protocol summarizing the safety requirements for the use of VMs through a PIV. These requirements included: a vein diameter > 4 mm, confirming placement of the PIV within the vein by ultrasound, appropriate PIV size (18 or 20 gauge), appropriate access positioning (no hand, wrist, or antecubital fossa sites), and blood return from the PIV access site prior to VM administration. According to the nursing protocol, the PIV site was assessed every 2 hours, and the medical team was alerted immediately if there was evidence of line extravasation. PIVs were limited to 72 hours maximum duration.
Nineteen patients (2%) experienced extravasation of the PIV access during the administration of the VM. These patients were treated with local phentolamine injection and application of local nitroglycerin paste without any evidence of tissue injury following treatment. Ninety-five (13%) of the patients who received VM through PIV access eventually required central intravenous access. The investigators concluded the administration of VM by PIV access was feasible and safe in this single-center medical ICU. They further concluded that clinicians should not regard the use of vasoactive medication as an automatic indication for central venous access.
COMMENTARY
VMs are necessary to improve hypotension in many critically ill patients. Traditionally, it has been standard of care to place a CVC prior to the administration of VM. Most intensivists have based this decision on the concern for local tissue injury due to the vasoconstrictive effect of the vasopressors. Although this study appears promising, a 2015 review that included 270 patients (from 85 primary studies or case reports) reported 325 separate local tissue injuries and extravasation events (318 events resulting from peripheral vasopressor administration and 7 events resulting from central administration).1 Local tissue injury was defined as an adverse event attributed to vasopressor administration occurring within close proximity to the infusion site, while extravasation of vasopressor was considered an escape of vasopressor medication from the vessel. There were 204 local tissue injury events (179 skin necrosis, 5 tissue necrosis, and 20 gangrene) from peripheral administration of vasopressors, with an average duration of infusion of 55.9 hours (± 68.1 hours). There were also 114 events of extravasation of vasopressor solution, with 24.6% of the events leading to tissue injury. Interestingly, this review highlights that tissue injury may occur without extravasation as a result of the profound effects of vasoconstriction local to the site of administration, leading to local tissue hypoperfusion.
Since the 2015 review was derived mainly from case reports, it is important to note that it may not be representative of general clinical practice outcomes, especially with the concern for publication bias. Regardless, it is apparent the 2015 review of the literature and the current study have disparate results. As already mentioned, this investigation maintained a strict protocol for IV placement and VM administration. Furthermore, the program also incorporated a multidisciplinary team that included training and education of the nursing staff and MICU house staff teams. If a patient experienced tissue extravasation, there was a standard treatment protocol, including treatment with phentolamine and nitroglycerin paste, implemented immediately. Given the disparate results found in the review and the current article, caution should be exercised in adhering to the recommendations made by the authors; PIVs may be safe only with a strict protocol that addresses training, education, and treatment. Without complete adherence to these protocols, the administration of VM through a PIV can be very risky. As intensivists, we also have to reflect on the potential consequences of such complications, which may include skin grafting with plastic surgery as well as how patients and families may react to this complication. The risks of PIVs must be weighed carefully with the known risks of CVCs, which may include infection, clot, bleeding, or pneumothorax. Regardless, the conclusion that “clinicians should no longer consider administration of norepinephrine, dopamine, or phenylephrine to be an automatic indication for CVC access” is dangerous. One cannot appropriately make this conclusion without a randomized, controlled trial comparing outcomes of VM use in critically ill, hypotensive patients with PIVs vs CVC.
REFERENCE
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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;30:653 e9-17.
