Mythbuster: Administration of Vasopressors Through Peripheral Intravenous Access

28 May
May 28, 2015

VasopressorsBackground: Vasopressors are frequently used in critically ill patients with hemodynamic instability both in the emergency department (ED) as well as intensive care units (ICUs). Typically, vasopressors are given through central venous catheters (CVCs) as opposed to peripheral intravenous (PIV) access due to the concerns about adverse events (i.e. tissue ischemia/necrosis) associated with extravasation through PIVs. In a truly hypotensive, critically ill patient the use of a PIV to administer vasopressors will allow the medication to stabilize the patient sooner and reduce the time to hemodynamic stability. The requirement to start vasopressors through a CVC may delay administration of pressors. Also, performing the insertion of a CVC in a hypotensive patient in an emergency circumstance versus an elective circumstance may increase the risk of adverse events from the procedure itself (i.e. bacteremia, pneumothorax, arterial puncture). Finally, most of the evidence cited for avoiding PIV administration of pressors is a sparse collection of case studies and expert opinion.

What Study are we Reviewing in this Post?

Loubani OM et al. 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.e17. PMID: 25669592

What They Did:

  • A systematic review of Medline, Embase, and Cochrane databases from inception through January 2014 for reports of adults who received vasopressor through PIV or CVC
  • Outcomes:
    • Local Tissue Injury = Adverse event attributed to vasopressor administration occurring within close proximity to the infusion site
    • Extravasation of vasopressor = Escape of solution containing vasopressor from vessel through which it is infused into surrounding tissue or body cavity
    • Major disability = Patient unable to return to previous level of function because of severe deficits from event

Results:

  • 85 articles with 270 patients and 325 separate local tissue injury and extravasation events included
  • 318 events were from PIV administration
    • 204 local tissue injury events (179 skin necrosis, 5 tissue necrosis, and 20 gangrene)
      • 85.3% of adverse events occurred from PIVs located at sites distal to antecubital or popliteal fossae
      • 96.8% of adverse events occurred after 4 hrs of infusion from PIV
      • Major disability and mortality in 9 (4.4%) and 4 (2.2%) of cases respectively
    • 114 extravasation events
      • 75.4% did not result in any tissue injury
      • 75% of adverse events were distal to antecubital and popliteal fossae
      • Major disability 3 cases (2.7%), and mortality 1 case (0.9%)
    • 7 events were from CVC administration
      • 4 local tissue injury events (3 skin necrosis & 1 gangrene)
        • Long-term sequelae 3 cases and minor disability 2 cases
        • Mortality in 1 case
      • 3 extravasation events
        • No injuries reported

Duration of Vasopressor Infusion

Duration of Infusion

Strengths:

  • This is the largest review to date looking at the use of vasopressors from PIVs

Limitations:

  • This was a systematic review, but many of the studies had information abstracted from charts, so there may be some reporting bias (i.e. some complications may not have been documented) which would underestimate complications
  • This review was only for complications from administration of vasopressor, and not a review of frequency of complications (i.e. instances where no complications occurred)
  • There was a large inconsistency of reporting among the published studies reviewed. Critical information to analyze the outcomes of interest were missing in a lot of published reports.

Discussion:

  • Currently administration of vasopressors via peripheral IVs is considered to be unsafe and often discouraged by some due to the concern of local tissue injury from extravasation, but this systematic review found only observational reports of complications of vasopressor infusion from PIVs.
  • There were 204 local tissue injury events from vasopressor infusion from PIVs, but most (85.3%) of the complications occurred from PIVs distal to the antecubital or popliteal fossae and infusions running >4 hours (96.8%).
  • Only one event was identified where local tissue injury occurred with infusion of vasopressor via PIV from <1 hour, which was a case of septic shock and an infusion of phenylephrine of unspecified dose via the saphenous vein of the left leg.
  • There was one RCT comparing complication rates from vasopressor administration of CVC vs PIVs by Ricard et al, which reported increased complication rates from peripheral IVs, but details of the location of the catheters, the nature of the vasopressor, and the duration of infusion were not reported.
  • The data from this review was derived mostly from case reports and case series and therefore may not be representative or typical of clinical practice, therefore no definitive conclusions can be drawn from this review about safety of PIV administration of vasopressors.

Study Conclusion:

Published data on tissue injury or extravasation from vasopressor administration via peripheral IVs are derived mainly from case reports and further study is warranted to clarify the safety of vasopressor administration via PIVs.

Clinical Take Home Point:

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.

References:

  1. Loubani OM et al. 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.e17. PMID: 25669592
  2. Ricard JD et l. Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med 2013; 41: 2108 – 15. PMID: 23782969
  3. Cardenas-Garcia J et al. Safety of Peripheral Intravenous Administration of Vasoactive Medication. J Hosp Med 2015. [Epub ahead of print]. PMID: 26014852

For More on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)

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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of R.E.B.E.L. EM
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13 replies
  1. Casey Parker says:

    Hey Salim
    Thanks for reviewing this – I saw it to and agree – its a patchwork SR with some interesting trends.

    For me its a risk:benefit equation – specifically risk of extravasation vs. risk of leaving the pt hypotensive / in a state of poor perfusion for another few hours until it is possible (resources, staff, skills) to get a CVC sited safely.
    A rushed CVC by an occasional operator is also a true clinical risk – hard to pick these out of the data.
    But if you take the cases series on face value – the graphic you show does suggest there is a real jump in complications after the 6 -12 hour mark.

    So I reckon we in resource -limited places can get by on a good PIVC “till daybreak” if we have crashing patients overnight… or at least until the cavalry arrives in a few hours 😉
    My rule – I will only use an IV in an arm if I would be happy to take the patient to theatre for an Emergency Caesarean with that as my access! Its a very practical definition of “Good IVC” in my head!
    Thanks
    Casey

    Reply
  2. Brett Rosen says:

    Great article, as always. I think it’s quite safe to use in at least an AC or more proximal. I could not agree with you more. I think the biggest use I have now is peri-intubation pressors – I will start pressors peripherally if borderline hypotensive and intubating, to attempt to avoid the peri-intubation arrest: “resuscitate before intubate.”

    I also think it’s reasonable at times to use peripheral dopamine – I wouldn’t in sepsis – but bradycardia/hypotension secondary to something like hyperkalemia, or a neurogenic shock patient for example – it’s not a huge deal if it extravasates.

    Do you happen to know – I went back to the abstract – they found 270 patients that had tissue injury – do you know the total number of patients this was out of? I wonder what the actual rate of occurrence is.

    Reply
    • Salim Rezaie says:

      Hey Brett,
      Really appreciate your support on the site and your critical eye on the posts. As far as your question…that was one of the limitations of this paper….I listed the below in that section:

      “This review was only for complications from administration of vasopressor, and not a review of frequency of complications (i.e. instances where no complications occurred).”

      I will email you the PDF of the paper though for your records.

      Salim

      Reply
  3. ash says:

    Just had a consultant and registrar laugh and criticize another registrar for transferring a patient on NA infusion running through a 16G 80 mm long Angiocath inserted under US guidance in the basilic vein.

    Reply
  4. Edward Snelson says:

    Hi Salim. Good article. Do you think the results apply to children?

    Reply
    • Salim Rezaie says:

      Hi Edward,
      Unfortunately the review was in adults 18 years and older. Children were not included so hard to draw conclusions in kids. Not aware of any reviews or large trials or reviews in the pediatric population either.

      Salim

      Reply

Trackbacks & Pingbacks

  1. […] Salim Rezaie at REBEL EM: Mythbuster – Administration of Vasopressors Through Peripheral Intravenous Access […]

  2. […] Salim Rezaie at REBEL EM: Mythbuster – Administration of Vasopressors Through Peripheral Intravenous Access […]

  3. […] The fact is that if you have a patient who needs a presser and there’s no central line it’s ok.  Yes, it may not be ideal, but if your patient is circling the drain and the BP tanks, what choice do you have.  So here’s your education FOAM ammo when confronted by the stank eye.  Thanks to REBEL EM for this one!  Myth buster: Administration of Vasopressors Through Peripheral Intravenous Access […]

  4. […] Peripheral Vasopressors are ok in critically ill, unstable patients in a proximal peripheral IV, for <6hours until central venous catheter is established (Paul Marik – Not on Twitter). […]

  5. […] about giving peripheral vasopressors prior to central access? Check out this post from Rebel EM. […]

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