Administration of vasopressors through peripheral venous catheters

Alan Araiza; Melanie Duran; Joseph Varon

doi:10.1503/cmaj.211966

Early administration of vasopressors in patients with septic shock improves patient outcomes

Despite advancements in sepsis management, mortality rates remain high. In 2011, 1 in 18 deaths in Canada involved sepsis.1 Delays in achieving adequate mean arterial pressure (MAP) are associated with increased mortality.2 Therefore, the Surviving Sepsis Campaign guideline recommends prioritizing treatment of low MAP through vasopressors given peripherally, rather than waiting for placement of a central venous catheter.3

When central venous access cannot be established delivering vasopressors via peripheral catheters is acceptable

Administration of vasopressors through peripheral venous catheters has traditionally been avoided given concerns of extravasation, limb ischemia and tissue necrosis.4 However, placement of central venous catheters requires special training, can be time consuming and can delay vasopressor initiation. In addition, central line insertion and maintenance can cause complications like pneumothorax (2.1%), catheter-related bloodstream infection (0.5%–1.4%) or deep vein thrombosis (0.5%–1.4%).5

Extravasation injury from vasopressors given through a peripheral catheter is uncommon

A meta-analysis of 16 055 patients treated with peripherally administered vasopressors reported an incidence of adverse events (i.e., extravasation, limb ischemia and necrosis) of 1.8% (95% confidence interval 0.1%–4.8%). The incidence did not differ significantly according to vasopressor type, or catheter location or gauge.5 Since 1 study found that extravasation was more likely with catheters placed below the antecubital fossa, placing the peripheral catheter as proximally as possible seems appropriate.4 Most extravasation events happened 6–50 hours after the infusion was started. Serious complications were uncommon even when extravasation occurred.4^,5

Risks of extravasation can be minimized with a few simple steps

If extravasation occurs, clinicians should stop the infusion immediately but not remove the catheter. While the vasopressor infusion is restarted through a new access site, the drug should be aspirated through the original catheter. The catheter can then be removed while aspiration is taking place. Phentolamine should be injected subcutaneously along the edges of the extravasation area. Surgical evaluation should be considered.4^,5

Institutional protocols should be considered when using peripheral vasopressors

Institutional protocols may contribute to the low incidence of complications. We propose an algorithm for clinical monitoring and management of extravasation in adult patients based on the limited published data and our clinical experience (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.211966/tab-related-content).4^,5

Footnotes

Competing interests: None declared.
This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

References

↵
1. Hennessy DA,
2. Soo A,
3. Niven DJ,
4. et al
. Socio-demographic characteristics associated with hospitalization for sepsis among adults in Canada: a census-linked cohort study. Can J Anaesth 2020;67:408–20.
OpenUrl
↵
1. Colon Hidalgo D,
2. Patel J,
3. Masic D,
4. et al
. Delayed vasopressor initiation is associated with increased mortality in patients with septic shock. J Crit Care 2020;55:145–8.
OpenUrl
↵
1. Evans L,
2. Rhodes A,
3. Alhazzani W,
4. et al
. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021;47:1181–247.
OpenUrl CrossRef PubMed
↵
1. Loubani OM,
2. 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.
OpenUrl
↵
1. Owen VS,
2. Rosgen BK,
3. Cherak SJ,
4. et al
. Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis. Crit Care 2021;25:146.
OpenUrl PubMed