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Peripheral pressors - what's the risk?
Background
In May the CENSER trial[1] looked at giving early vasopressors to patients in septic shock. They found that this reduced the time to shock control, risk of pulmonary oedema and mortality at 28 days. We covered this paper on The BREACH - click here.
One potential barrier to adopting this approach in the ED is the perceived need to give vasopressors via a central line. In some hospitals getting central access can be somewhat time-consuming, and may even require conversations with anaesthetics.
But what if you could start a noradrenaline infusion through a good peripheral line? On the one hand, prolonged hypotension and over-administration of IV fluid are bad for your patient. On the other hand, peripheral vasopressors can cause irreversable skin damage if extravasation occurs.
How can we balance these risks? Are both equally risky? This paper strongly suggests they are not. Let's check it out...
The paper
Pancaro C, Shah N, Pasma W, Saager L. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2019 Sep [epub ahead of print][2]
A retrospective observational study of 14,385 patients who received noradrenaline via a peripheral line during elective surgery. The paper looked at all cases over a period of 4 years in two Dutch hospitals. The aim was to estimate the risk of complications, in particular skin damage following accidental extravasation.
The noradrenaline was diluted to 20 ug/ml and given at a rate of 40-300 ug/hr, titrated to a satisfactory blood pressure.
There were a total of 5 extravasation events (0.035%). Each had a severity grade of 1, meaning no necrosis, erythema or signs of irritation.
Why is this complication rate so tiny?
The authors put forward the following suggestions:
The anaesthetist was able to monitor the IV site closely and could stop the infusion quickly if extravasation occured. (However I know from experience that anaesthetists do not spend their whole time during surgery staring at a cannula site... How would all those Sudoku puzzles get done?)
The patients were undergoing elective surgery and were not acutely unwell or in profound shock. Their peripheral circulation was therefore able to reabsorb the noradrenaline quickly.
Limitations
Like any retrospective observational study, these results depend to a large extent on the reporting accuracy of the clinicians involved. However, the authors describe a robust system of adverse event reporting, established for many years and involving staff at every level.
Secondly, this study was carried out under different conditions and involved a different patient population to that seen in the ED. It was carried out in one country, where practices and systems may differ considerably from mine or yours.
The bottom line
In this analysis of over 14,000 cases of peripheral norepinephrine infusion, there were only 5 extravasation events and no complications. Peripheral pressors are safe under these conditions.
What can we do to further minimise the risk?
A systematic review in 2015[3] looked at all the cases of extravasation from peripheral vasopressor administration in the literature. They found 318 events, collected mainly from case reports. They found that 95% of the events occured in infusions that had been running for over 4 hours, and that 85% of the events occured in IV lines placed distal to the antecubital fossa.
So, to reduce the risk of extravasation and skin necrosis:
Use a good proximal line
Don't leave it running for ages
Check it frequently
More FOAMed on this
REBEL EM - Peripheral vasopressors: safe or dangerous?REBEL EM - Mythbuster: administration of vasopressors through peripheral IV accessFirst 10 EM - Peripheral vasopressors: the myth and the evidencePulmCrit - Do phenylephrine and epinephrine require central access?EM Crit - Peripheral vasopressor infusions and extravasation
References
Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med [Internet] 2019;199(9):1097–105. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30704260
Pancaro C, Shah N, Pasma W, Saager L, Cassidy R, van K, et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg [Internet] 2019;Available from: https://www.ncbi.nlm.nih.gov/pubmed/31569163
Loubani O, Green R. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care [Internet] 2015;30(3):653.e9-17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25669592
View all episodes
By Barrie StevensonBackground
In May the CENSER trial[1] looked at giving early vasopressors to patients in septic shock. They found that this reduced the time to shock control, risk of pulmonary oedema and mortality at 28 days. We covered this paper on The BREACH - click here.
One potential barrier to adopting this approach in the ED is the perceived need to give vasopressors via a central line. In some hospitals getting central access can be somewhat time-consuming, and may even require conversations with anaesthetics.
But what if you could start a noradrenaline infusion through a good peripheral line? On the one hand, prolonged hypotension and over-administration of IV fluid are bad for your patient. On the other hand, peripheral vasopressors can cause irreversable skin damage if extravasation occurs.
How can we balance these risks? Are both equally risky? This paper strongly suggests they are not. Let's check it out...
The paper
Pancaro C, Shah N, Pasma W, Saager L. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2019 Sep [epub ahead of print][2]
A retrospective observational study of 14,385 patients who received noradrenaline via a peripheral line during elective surgery. The paper looked at all cases over a period of 4 years in two Dutch hospitals. The aim was to estimate the risk of complications, in particular skin damage following accidental extravasation.
The noradrenaline was diluted to 20 ug/ml and given at a rate of 40-300 ug/hr, titrated to a satisfactory blood pressure.
There were a total of 5 extravasation events (0.035%). Each had a severity grade of 1, meaning no necrosis, erythema or signs of irritation.
Why is this complication rate so tiny?
The authors put forward the following suggestions:
The anaesthetist was able to monitor the IV site closely and could stop the infusion quickly if extravasation occured. (However I know from experience that anaesthetists do not spend their whole time during surgery staring at a cannula site... How would all those Sudoku puzzles get done?)
The patients were undergoing elective surgery and were not acutely unwell or in profound shock. Their peripheral circulation was therefore able to reabsorb the noradrenaline quickly.
Limitations
Like any retrospective observational study, these results depend to a large extent on the reporting accuracy of the clinicians involved. However, the authors describe a robust system of adverse event reporting, established for many years and involving staff at every level.
Secondly, this study was carried out under different conditions and involved a different patient population to that seen in the ED. It was carried out in one country, where practices and systems may differ considerably from mine or yours.
The bottom line
In this analysis of over 14,000 cases of peripheral norepinephrine infusion, there were only 5 extravasation events and no complications. Peripheral pressors are safe under these conditions.
What can we do to further minimise the risk?
A systematic review in 2015[3] looked at all the cases of extravasation from peripheral vasopressor administration in the literature. They found 318 events, collected mainly from case reports. They found that 95% of the events occured in infusions that had been running for over 4 hours, and that 85% of the events occured in IV lines placed distal to the antecubital fossa.
So, to reduce the risk of extravasation and skin necrosis:
Use a good proximal line
Don't leave it running for ages
Check it frequently
More FOAMed on this
REBEL EM - Peripheral vasopressors: safe or dangerous?REBEL EM - Mythbuster: administration of vasopressors through peripheral IV accessFirst 10 EM - Peripheral vasopressors: the myth and the evidencePulmCrit - Do phenylephrine and epinephrine require central access?EM Crit - Peripheral vasopressor infusions and extravasation
References
Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med [Internet] 2019;199(9):1097–105. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30704260
Pancaro C, Shah N, Pasma W, Saager L, Cassidy R, van K, et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg [Internet] 2019;Available from: https://www.ncbi.nlm.nih.gov/pubmed/31569163
Loubani O, Green R. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. J Crit Care [Internet] 2015;30(3):653.e9-17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25669592