Written by Michael Stocker
Spoon Feed
Even at high concentrations, prehospital peripherally-administered vasopressor infusions were generally safe, with few complications and no tissue damage reported at 24-hour follow up.
Profiling prehospital peripheral pressors
Infusion of vasopressors via peripheral access is an established, relatively safe practice in acute care. However, can we say the same for the prehospital setting, where logistic challenges may necessitate carrying higher concentration formulations? This prehospital observational cohort study investigated safety events and complications among patients (n=468) receiving peripheral infusions of norepinephrine (n=339), epinephrine (n=100), or both (n=29) during transport. Note that the drug concentrations were often substantially higher than those recommended by Intensive Care Society guidelines (60 mcg/mL vs 16 mcg/mL). Both medical and trauma patients were analyzed, with exclusion criteria including death before or in transit and conversion to external jugular or central line access. Median doses for norepinephrine were 9mcg/min when alone and 20mcg/min with epinephrine, and 10 mcg/min for epinephrine regardless of additional pressors. There were 4 in-transit conversions to central access, though these were noted to be performed for provider preference rather than directly linked to an issue with the peripheral infusion. Catheter kinking or line pressure alarms were the most common issue (2.7%). Infiltration or cannula dislodgment occurred 3 times (0.6%), but no tissue complications were reported at 24 hours. Selection bias may weigh heavily here: patients who already had central lines were not included, which may exclude a sicker population on higher-dose pressors. Additionally, vasopressin and other agents were not investigated.
How will this change my practice?
I’ll feel safer foregoing the risks of a central line for most pressor-dependent transfers with adequate peripheral access, even if my local critical care transport service carries high-concentration pressors. Peripheral pressors have been in vogue since I started my ED and prehospital practice, and I don’t see them going away any time soon.
Source
Safety of Peripheral Vasoactive Drug Administration in Prehospital and Retrieval Medicine (SPOTLESS-2): A Prospective Observational Cohort Study. Acad Emerg Med. 2026 Apr;33(4):e70271. doi: 10.1111/acem.70271. PMID: 41947342.
