First thing that probably comes to mind when you hear peripheral vasopressors is “when is this patient getting a central line (CVC)?” or “COWBOYS!” because as ED docs that is what we are and how else to express that best than sticking things in places they shouldn’t be?!  Like… Peripheral Vasopressors (VM)!!

 

Why don’t we use them?  Extravasation of VM resulting in local tissue ischemia/gangrene/bad things

 

 

What does the literature say?

The Good: Cardenas-Garcia et al 2015

  • Study Design:
    • Prospective study of 783 patients who received VM via PIV
    • VM used: (1) NorEpi  (2) Dopamine  (3) Phenylephrine
    • The clinical team decided if patient needed CVC or PIV  for VM
    • vein>4mm measured w/ US
    • upper extremity only w/ size 18g (25% of patients) or 20g (75%) IV with alot of long IV catheters (approx 15cm)
    • No hand, wrist, AC fossa PIV
    • 72hrs maximum duration of PIV use
    • q2hr nursing checks of PIV
    • phentolamine and nitroglycerin paste for rescue therapy
    • There’s more…
  • Results:
    • 19 (2%) adverse events(AEs) aka extravasation  (16 NorEpi/3 Dopamine)
    • 13% of patient who initially had PIV needed CVC
  • Limitations:
    • Single-center study
    • No comparison CVC group

The Bad: Richard et al 2013 reviewed by EMCrit

  • Study Design: 
    • RCT between 135 patients in CVC group and 128 patients in the PIV group
    • PIVs 18 or 20g and standard IVs (3-5cm)
    • PIV patients could “crossover” to CVC patient if there was need for increased VM or difficulty with maintaining/obtaining PIV
  • Results: 
    • Significantly more “major” (ex: extravasation, PIV insertion difficulties…) AEs in PIV group: 133 PIV/87 CVC (p<0.02)
    • Significantly less AEs in patients who received PIV and then subsequent CVC (p<0.005)
    • No significant difference in AEs between patient who initially had PIV and then converted to CVC compared to group who initially had CVC
    • 67 patients with initial PIV received a subsequent CVC
  • Limitations:
    • “Major”/”Minor”AEs are vaguely defined and…after Scott Weingart wrote to the authors they said that everyone in the PIV group who had AEs actually did fine…lol
    • No use of US
    • Uncertain location on PIVs
    • Uncertain what VM were associated with what percentage of complications

The Ugly: Loubani et al 2015 reviewed by RebelEM

  • Study Design:
    • systematic review 85 articles with 270 patients who received VM via PIV or CVC where something went wrong
  • Results:
    • 325 total AEs (CVC and PIV) extravasation
    • 318 associated w/ PIV use
    • 204 resulting in injury (179 skin necrosis, 5 tissue necrosis, and 20 gangrene)
      • 85.3% adverse events 2/2 PIVs distal to AC 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
      • Majority of events were w/ NorEpi  (80.4%) followed by Dopamine (9.3%) and Vasopressin (6.9%)
  • Limitations:
    • Unknown IV gauge in most studies
    • Various studies with various study designs and did not compare PIV w/o complications to those with complications from VM

The FIX!

Phentolamine can be used if extravasation occurs during vasopressor administration: (adapted from Table 2. Cardenas‐Garcia et al 2015)

  1. Stop VM immediately
  2. Aspirate residual medication through PIV and remove catheter
  3. Outline the extent of the extravasation is to provide a baseline for monitoring
  4. Reconstitute two 5mg vials of phentolamine with 5 mL of NS per vial to yield a final concentration of 1 mg/mL.
  5.  Inject phentolamine in 0.5- to 1-mL aliquots in 5 separate injections around the leading edge of the extravasation, using separate 25-gauge or 27-gauge needles for each injection.
  6. Last apply nitroglycerin paste (2.5 cm) is to the area of extravasation (from prior study in peds)

RECAP: If you’re going to use a PIV for a vasopressor…

  • Use large vein (>4mm) above AC fossa only in upper extremities
  • Use a long IV catheter (approx 15cm)
  • Do not use BP cuff on same side as
  • Avoid use for more than 72hrs and consider CVC if needed for longer duration
  • Opt for phenylephrine if appropriate
  • More studies!

 

Sources

  • http://foamcast.org/2015/07/25/episode-31-vasopressors/
  • http://emcrit.org/podcasts/peripheral-vasopressors-extravasation/
  • http://www.emdocs.net/r-e-b-e-l-em-mythbuster-administration-of-vasopressors-through-piv/
  • Cardenas‐Garcia, J., Schaub, K. F., Belchikov, Y. G., Narasimhan, M., Koenig, S. J., & Mayo, P. H. (2015). Safety of peripheral intravenous administration of vasoactive medication. Journal of hospital medicine, 10(9), 581-585.
  • Loubani, O. M., & Green, R. S. (2015). A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. Journal of critical care,30(3), 653-e9.
  • Ricard, J. D., Salomon, L., Boyer, A., Thiery, G., Meybeck, A., Roy, C., … & Dreyfuss, D. (2013). Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Critical care medicine, 41(9), 2108-2115.