Useful Critical Care resources
There are currently no guidelines for clinicians on the safe administration of peripheral vasopressors in the Emergency Department for adults. There is evidence of their use in emergent situations as a temporising measure, however there is a paucity of literature to guide clinicians on their safe use.
Vasoactive drugs have traditionally been given via a central line due to the risks of extravasation, and delayed until adequate fluid resuscitation has been given, and central access obtained. However, a growing body of evidence suggests early use of inotropes is associated with improved outcomes 1,2.
Evidence and Background
Many emergency physicians are already using peripheral vasopressors despite a lack of established guidelines. A recent systematic review conducted by Loubani et al. (2015)3, and an observational study byCardenas-Garcia et al (2015)4 suggests that under certain circumstances they can be safely administered peripherally.
1.The systematic review looked at 85 articles and found 270 patents receiving vasopressors with a total of 325 adverse events. 318 of these were given peripherally. Of the adverse events 204 were actual tissue injury including skin / tissue necrosis and gangrene. The other adverse events were extravasation without tissue injury. The majority of bad outcomes were in patients receiving noradrenaline, administered peripherally to the antecubital fossa for > 6 hours.
2.The observational study looked at 783 patients receiving peripheral vasopressors. They had very strict guidelines for peripheral use including:
- vein diameter >4mm measured on USS
- Upper limb only
- Cannula 18 or 20 guage
- No hand, wrist or antecubital fossa
- Able to draw blood from cannula prior to use
- Assessment of cannula function every 2 hours
- 72 hours maximum use
Extravasation occurred in just 19 patients (2%). These were treated with a strict protocol of phentolamine and GTN paste at the site of extravasation. There were NO cases of tissue damage due to extravasation
The ECI reviewed IIMs data over 3 years looking at incidents relating to the peripheral use of vasopressors and inotropes. During this period 492 incidents were found with 34 directly related to the peripheral use of vasopressors. Of these 26 were related to peripheral administration of NA. Of these ‘incidents’, the majority were reports of NA being used peripherally but with no bad outcomes, indicating the need for a policy, and education around the use of peripheral NA. Actual incidents that occurred included 1 patient with skin damage, 1 patient with hypertension due to flushing the line, 1 patient who received a subtherapeutic dose due to peripheral administration, and 1 patient with delay to receiving the drug due to lack of a central line.
We surveyed 210 doctors around the state regarding their use of vasopressors in the past 5 years. 102 doctors (49%) are already using peripheral NA with a reported complication rate of 5.9% (4 patients experienced arrhythmias, 1 had pain from the infusion, and 1 was reported as “other / unknown”). Of the 210 doctors surveyed only 51 (26.7%) reported having a guideline to follow regarding the use of peripheral noradrenaline.
Clinical Bottom Line
Peripheral vasopressors are safe. Use the guidelines we provide here or develop your own based on these and include your critical care partners.
- Indications for noradrenaline are management of acute hypotension due to septic shock and other causes of distributive shock.
- The 2012 Surviving Sepsis Guidelines5 recommend noradrenaline and dopamine as the first-choice agents for hypotension following adequate fluid resuscitation and source control. The recommended end-point is a MAP of 65 mmHg for most patients.
- Due to risks of extravasation, it is recommended that where possible noradrenaline is given centrally. However, it is important not to delay appropriate vasopressors when it is identified that a patient needs them for treatment of shock and low perfusion states. Where the timely insertion of a central line is not possible we recommend starting a peripheral infusion.
Contraindications / Precautions
- Hypovolaemia—correct before using noradrenaline.
- Hyperthyroidism, ischaemic heart disease—increases risk of cardiovascular adverse effects.
- Rapid Onset
- Duration of action 1-2 mins
- Half life 1-2 mins
- Aseptic technique for insertion of line
- Peripheral line only to be used for maximum of 6 hours
- 18G cannula or larger
- Use in upper limb only. Not to be used in antecubital fossa or hand
- Check position with ultrasound if possible
- Dedicate line solely to noradrenaline
- BP monitoring – Insert an arterial line ASAP
- Monitor NIBP and pulse every 5 minutes until invasive monitoring available
- Continuous ECG
- Monitor peripheral vein infusion site every hour for blanching or extravasation
- Peripheral noradrenaline should not run for greater than 6 hours
- Aspirate line prior to cessation of infusion
- There is no evidence that lower concentrations reduced complications, therefore the infusion should be made up to standard concentration as per local hospital policy to avoid confusion regarding the concentration.
- A suggested concentration would be 6mg (6mL of 1:1000) Noradrenaline in 94mL 5% Dextrose ( or Normal Saline) to make 100mL = concentration of 0.06mg/ml
- For syringe drivers use 3mg (3 mL of 1:1000) Noradrenaline in 47mL 5% Dextrose (or Normal Saline) = concentration of 0.06mg/ml
- Commence at 1-5mls/hr and titrate to effect
Further infusion and administration advice can be found in the Australian Injectable Drug Handbook http://aidh.hcn.com.au/browse/n/noradrenaline
For a quick reference guide from NSW Retrieval services go here.
Extravasation / skin changes
- Stop infusion and disconnect infusion, leaving the cannula in place
- Patient may be dependant on vasopressor infusion – get alternative access and recommence infusion at alternative site
- Attempt to aspirate residual drug from the cannula
- Remove cannula whilst aspirating
- Infiltrate phentolamine locally via 25G or smaller needle. Prepare by diluting 5 mg phentolamine in 10 mL of 0.9% sodium chloride. Dose of 0.1-0.2mg/kg up to max of 5mg. This can be done within 12 hours of extravasation, and blanching should reverse immediately.
- Elevate the limb for 24 hours
- Mark affected site
- Request plastics consult ASAP
Other adverse effects- reflex bradycardia, palpitations, hypertension
- Reduce rate of infusion, consider changing to an alternative vasopressor if unable to achieve required MAP without side effects.
Further References and Resources
- Bai, X., Yu, W., Ji, W., Lin, Z., Tan, S., Duan, K., ... & Li, N. (2014). Early versus delayed administration of norepinephrine in patients with septic shock. Crit Care, 18(5), 532-533.
- Timing of vasopressor initiation and mortality in septic shock: a cohort study. Crit Care. 2014 May 12 ;18(3):R97. doi: 10.1186/cc13868.
- Loubani OM, Green RS. A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters. Journal of critical care. 2015;30(3):653 e9-17.
- Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015 Sep ;10(9):581-5. doi: 10.1002/jhm.2394. Epub 2015 May 26 .
- Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580–637
Adapted from Calvary Mater Newcastle Department Drug Guideline
Peripheral Vasopressors - Dr Lucy Lutze at the ECI Emergency Care Symposium 2015