The Safety of Peripheral Vasopressor Administration
Introduction
Imagine rushing a critically ill patient into the resus room, their blood pressure plummeting, and every second ticking away like a time bomb. In these moments, vasopressors—medications that constrict blood vessels and elevate blood pressure—are lifesavers. Traditionally, these potent drugs are administered through central venous catheters (CVCs). However, placing a CVC takes precious time and skill, resources that might not be immediately available.
Here lies the charm and challenge of peripheral vasopressor administration. While using a peripheral intravenous catheter (PiVC) allows quicker delivery of the medication, it comes with the fearsome risk of extravasation—a leakage of the drug into surrounding tissues. If unchecked, extravasation can cause severe tissue damage, compromising the limb and even risking potential loss of life.
This blog post delves into the critical balance of safety and efficacy in using peripheral vasopressors, drawing insights from a recent systematic review to evaluate their safety, analyze adverse events, and recommend protocols for clinical practice.
Evaluating the Safety of Peripheral Vasopressor Administration
A recent systematic review titled "Safety of peripheral administration of vasopressor medications: A systematic review"aimed to resolve this dilemma by scrutinizing the safety of PiVCs for vasopressor administration. The review sifted through prospective and retrospective studies, meticulously collecting data from seven studies involving a total of 1,382 patients.
The objective was to assess peripheral administration's safety profile by focusing on patient factors, cannulation approach, monitoring protocols, vasopressor dosing, and adverse events. Intriguingly, noradrenaline emerged as the most frequently used vasopressor with an average infusion duration of 22 hours.
Key results highlighted that extravasation occurred in just 3.4% of the cases. More reassuringly, none of these incidents escalated to severe complications such as tissue necrosis or limb ischemia. This underpins the conclusion that with vigilant monitoring, PiVCs can safely deliver vasopressors, offering a viable alternative to CVCs in emergency scenarios.
Extravasation and Adverse Events
Extravasation is the ghost that haunts the hallways of peripheral vasopressor administration, feared for its potential to cause catastrophic tissue injuries. However, the review's data reveals a different story. Out of 1,382 patients, only 3.4% experienced extravasation, and among these, none developed life-threatening issues like tissue necrosis or limb ischemia. This is a clear indication that severe complications are rare and manageable.
A case from the review illustrates this point vividly. A patient receiving noradrenaline via PiVC faced extravasation but was managed successfully using conservative measures, involving vasodilatory medications. This highlights that extravasation, while concerning, can be effectively contained without drastic outcomes.
Avoiding Extravasation and Ensuring Safety
The cornerstone of safe peripheral vasopressor administration lies in proactive prevention and prepared management. Here are the steps to mitigate the risk of extravasation:
- Close Monitoring: Regularly inspect the PiVC site for signs of leakage, swelling, or discomfort. Early detection is crucial.
- Protocol Adherence: Establish and follow detailed institutional protocols for placing, monitoring, and managing PiVCs.
- Educate Staff: Train healthcare providers on recognizing the early symptoms of extravasation and the steps to take if it occurs.
- Use of Diluted Solutions: Administering vasopressors at the lowest effective concentration can reduce the risk of causing tissue damage in case of leakage.
- Prompt Action: In cases where extravasation occurs, immediate steps such as discontinuing the infusion and employing antidotes like vasodilators are essential.
Implications for Clinicians
What does this mean for the clinicians on the front lines? The review's findings suggest that peripheral administration of vasopressors could be a game-changer in high-pressure situations requiring rapid intervention. It enables quicker drug delivery without the need to wait for a CVC placement, which can be lifesaving.
For best practices:
- Utilize PiVCs judiciously: Consider PiVCs for vasopressor administration in time-critical scenarios with the understanding that short-term usage under close surveillance is key.
- Develop Protocols: Instituting comprehensive protocols for PiVC use ensures safety and standardizes care, minimizing the risk of complications.
- Focus on Training: Ensuring that the clinical staff is well-trained in both the placement and monitoring of PiVCs can greatly reduce the risk of adverse events.
Selection of Appropriate Peripheral Intravenous Cannulae (PIVC)
There is some evidence to show that the cautious selection of a suitable PIVC site as well as the below preventative measures may reduce the risk of extravasation of vasoactive medications.
• Upper extremity only, contralateral to the blood pressure cuff
• Intravenous line location and size requirements:
- Well sited large bore IV cannula (PIVC) of at least 18 gauge or larger
- Ideally brachial or cephalic vein at or above the elbow or
- Alternatively a large bore PIVC of at least 18 gauge in the antecubital fossa vein
- No hand, wrist or forearm peripheral IV (PIV) access
- Do not insert an IV cannula distal to a previous puncture site
- Ensure patency of the PIVC prior to administration by checking that aspiration of blood from the PIVC access is easily possible every 2 hours
- No resistance is present when flushing with 10ml 0.9% Saline
- Intravenous infusion runs freely
- 12 hours maximum duration of PIVC access use.
Extravasation Injuries from Peripheral Vasopressors
Extravasation should be suspected if the following occurs:
• Patient complains of burning, stinging, pain or discomfort
• Evidence of swelling, oedema, discoloration of surrounding skin (pale or erythema) or leakage at the site
• Absence or change of infusion flow
• Repeated pump alarms
• Increase in resistance when administering IV saline bolus.
If extravasation is suspected, the following steps are suggested:
- STOP the infusion
- If the patient is relying on the agent for their hemodynamics, switch the vasopressor to another IV (see above conditions for peripheral IV access) or place an immediate IO or central line.
- LEAVE the cannula in place
- ASPIRATE as much of the drug as possible from the cannula using a 3ml syringe
- CALL for help
- ASSESS the affected area for presence of symptoms e.g. skin discoloration, swelling
- TRACE the affected area with a marker pen
- REMOVE the IV cannula.
- Ensure hemostasis.
- Do NOT apply pressure
- APPLY GTN PASTE (this is NOT the patch) at a concentration of 0.2% (i.e. Rectogesic ® ) to the affected area - approx. a 2.5 cm strip of paste and cover with Opsite
- DO NOT use a GTN patch that acts slowly, DOES NOT offer any advantage and MUST NOT be used.
- MONITOR and REVIEW the affected area HOURLY for evidence of tissue ischemia
- DOCUMENT findings and neurovascular observations HOURLY
- COMMUNICATE adverse event and findings promptly
- An incident notification must be lodged via the Datix Clinical Incident Management System
Conclusion
In summary, the systematic review provides a breath of relief, underscoring that peripheral administration of vasopressors is not the specter it was once thought to be. With a low incidence of extravasation and absence of severe complications, it stands as a viable option, particularly when rapid intervention is critical.
Understanding the balance between speedy medication delivery and safety is crucial. By adhering to strict monitoring protocols and being prepared to manage any extrusion incident promptly, peripheral vasopressor administration can be life-saving without compromising limb integrity. As healthcare providers, integrating these findings into clinical practice can enhance patient outcomes in emergency settings, broadening the horizons of critical care interventions.
Implications for Clinicians
- Peripheral administration of vasopressors can be considered safe for short durations with proper monitoring.
- This approach can be useful when immediate vasopressor administration is critical, and CVC placement is delayed.
Future Research
- Need for more high-quality studies comparing PiVC and CVC administration of vasopressors.
- Detailed reporting on adverse events, dosing, and monitoring protocols is essential for future studies.
Bibliography Citations:
Tian, D. H., Smyth, C., Keijzers, G., Macdonald, S. P. J., Peake, S., Udy, A., & Delaney, A. (2020). Safety of peripheral administration of vasopressor medications: A systematic review. *Emergency Medicine Australasia, 32*(2), 220–227. https://doi.org/10.1111/1742-6723.13406
Western Australian Country Health Service (WACHS). (2018). Peripheral Vasopressor Infusion Guideline - Adults. Retrieved from WACHS HealthPoint Policies.
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Disclaimer:
The information provided in this article is intended for educational and informational purposes only. It should not be construed as medical advice, diagnosis, or treatment. Readers are advised to consult with qualified healthcare professionals for personalized medical advice, diagnosis, and treatment tailored to their specific needs and circumstances.
Furthermore, while medication names and dosages may be mentioned, it is imperative to adhere to local medical guidelines, protocols, and regulations when prescribing or administering any medication. The author(s) of this article do not assume any legal responsibility for the accuracy, completeness, or appropriateness of medication usage or dosages mentioned herein.
Medical practice varies regionally, and healthcare providers should exercise their clinical judgment and adhere to local standards of care when making medical decisions. Any reliance on the information provided in this article is at the reader's own risk.