Resus of the Hypotensive Patient Part 2 - Why You Should be Using Peripheral Pressors (and not feeling guilty about it)

https://en.wikipedia.org/wiki/Intravenous_therapy

Hypotensive patients who require large volume resuscitation to support their blood pressure are at risk of excessive IV fluids.  Using vasoactives appropriately can help mitigate these potential harms.  But let's be honest . . .  starting a vasopressor can sometimes be hard emotionally and cognitively.  One main reason is that it means more work…. it may require a different level of care, more phone calls, a different admitting service, and has been synonymous with placing a central line.  All of this takes time and can be difficult.  

How can we make starting vasopressors easier?  Consider peripheral vasopressors.  Giving vasopressors peripherally is safe and evidence-based.  Old data (mostly case reports) suggest extravasation is a relatively rare event.  Let's take a look at more recent evidence by Cardenas-Garcia et al.

This outcome was impressive from both a resource and patient oriented stand point.  Avoiding a central line means these ICU patients were not exposed to all the potential complications and discomfort associated with them.

So how do we start peripheral vasopressors safely?

In this study extravasation of the peripheral IV during administration of vasoactive medication occurred in 19 patients (2%) without any tissue injury following treatment (local phentolamine injection and application of local nitroglycerin paste).

While rare, we need to be prepared to treat extravasation injuries.  

Additional FOAMed Resources

1.  Are central lines really needed for vasopressor infusions? blog post on PulmCCM

2.  Peripheral vasopressor infusions on EMCRIT

Tired of reading?  watch Dr. Mackenzie discuss starting peripheral pressors

Recorded at the Maine Medical Center Winter Symposium in 2017

David Mackenzie, MDCM, FRCPC, FACEP

Assistant Professor of Emergency Medicine
Maine Medical Center
Tufts University School of Medicine

References

1. Ricard JD, Salomon L, Boyer A, et al. Central or peripheral catheters for the initial venous access of ICU patients: a randomized control trial. Crit Care Med. 2013; 41(9):2108-15.  [Pubmed]

2. Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015; 10(9):581-5. [Pubmed] 

Written by Jeffrey A. Holmes, MD

Content and original authorship by David Mackenzie, MDCM, FRCPC, FACEP