Written by Jason Lesnick
This prospective observational cohort study found implementing a protocol for peripheral norepinephrine (NE) decreased median number of central venous catheter (CVC) days per patient by one, and 51.6% avoided a CVC entirely.
Peripheral pressors prevent patients from pokes
Classically, administration of vasopressors requires a CVC to avoid local tissue injury if extravasation occurs, but placement of a CVC often delays vasopressor administration, involves risk of procedural complications, and risks central line infection. These researchers studied whether a protocol for peripheral NE would result in decreased CVC days and CVC placement.
The protocol evolved over time and initially required: 2 peripheral IVs 20 or 22 g, above wrist and below AC fossa, ultrasound placed and confirmed, patency assessed q2h, max dose NE 15 mcg/min, max infusion time 48h, and required that patients be able to report pain at site. Over time, they added an automated page to a nurse supervisor to assess for protocol adherence when the peripheral NE order was placed, included 18g IV, added q2h aspiration for blood return to patency checks, and removed the 48h limit and patient reporting requirement.
This single site prospective observational cohort study in the MICU at a quaternary academic hospital from 2/2019 to 6/2021 enrolled 635 patients who required norepinephrine and found the use of peripheral NE decreased median CVC days by 1 day per patient, and of the 603 patients who received peripheral NE, 311 (51.6%) of them never received a CVC. The median max dose of NE was 10 mcg/min but 14.6% of patients received a dose > 15 mcg/min during peripheral administration; 20.5% of patients received peripheral NE > 24 hours. The median time from initial peripheral NE administration to CVC placement was 3.6 hours (IQR 1.5, 12.5 hours) in those who required a CVC.
Notably, 35 (5.5%) patients had an extravasation event. 60% of these were grade 0 to 1 (i.e. very mild) according to the Infusion Nurses Society Infiltration Scale. 37% were grade 2 (skin blanched and translucent, edema 1-6 inches in any direction, cool to touch, with or without pain). The remaining one was ‘grade 4’ but involved a patient who expired before being evaluated by the study team; study policy suggested initially marking all extravasations as grade 4 in the EMR. No patients required surgery for compartment syndrome. Of the 35 patients with extravasation, 17 (48.6%) received a CVC; otherwise, the NE was continued in a separate peripheral IV.
How will this change my practice?
This reaffirms my practice that it is generally quite safe to use peripheral NE (if your hospital has a protocol in place). I was glad to see that their protocol changed to allow use of 18 gauge IVs. We know with regards to CT contrast administration, a 22g is more likely to have extravasation relative to an 18 or 20g – so, I will continue to preferentially use US guided 20 g or larger for my peripheral vasopressors.
Peripheral administration of norepinephrine: a prospective observational study. Chest, S0012-3692(23)05350-3. 21 Aug. 2023, doi:10.1016/j.chest.2023.08.019