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Peripheral Pressors for All? Peripheral Norepinephrine Infusion

November 21, 2019

Written by Sam Parnell

Spoon Feed
Short infusion of peripheral IV norepinephrine was very safe, with estimated risk of 1-8 extravasation events per 10,000 patients and no serious complications requiring medical or surgical intervention.

Why does this matter?
In medical school, I was taught that all patients requiring vasopressor support should have central lines. However, insertion of central venous catheters is associated with several serious complications as well. In addition, several recent small studies have supported the efficacy of peripheral vasopressor administration. Could peripheral IV pressors be a safe alternative and reduce the need for central venous access in some patients?

How safe is peripheral norepinephrine?
This was a retrospective cohort study analyzing 14,385 patients who received peripheral IV norepinephrine infusion for hypotension while undergoing elective surgery in the Netherlands. The median size of the peripheral intravenous line (PIV) was 18 gauge; 60% of IVs were placed in the antecubital fossa. The norepinephrine concentration was 20 µg/mL, and the median infusion duration was 20 minutes. Only 5 patients (0.035%) experienced extravasation, with no serious complications or skin necrosis reported. This suggests an estimated risk of 1-8 extravasation events per 10,000 patients. Of note, all complications were minor and resolved without medical or surgical intervention. It is difficult to extrapolate the results of this anesthesia study – with closely monitored IV sites, low doses, and brief infusions – to ICU or ED patients in shock who are receiving high doses and longer duration infusions of peripheral norepinephrine.

Nevertheless, this large study suggests that the risk of extravasation is very low and serious adverse events are exceedingly rare for peripheral norepinephrine infusion, especially when closely monitored and used for a short amount of time. However, further study is needed to investigate the safety of high-dose, long-term, peripheral vasopressor infusions. So, don’t throw out all those central line kits just yet…

Another Spoonful
See the take from REBEL EM.

Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2019 Sep 27. doi: 10.1213/ANE.0000000000004445. [Epub ahead of print]

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Reviewed by Clay Smith

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