For more in-depth information, see detailed post below!
Background
Traditionally, vasopressors have been administered via central venous catheter (CVCs). Intra-osseous (IO) routes have also been a viable alternative, if available.
Administration via peripheral intravenous (PIV) access has been avoided due to the long-standing concern for ischemic tissue injury from peripheral extravasation with smaller veins. Therefore, the administration of vasopressors could potentially be delayed if a CVC or IO access is not readily available.
Answer
The 2021 Surviving sepsis campaign guidelines suggest starting vasopressors peripherally to restore mean arterial pressure (MAP) rather than delaying initiation until CVC is secured. The statement is based on several clinical trials showing that the rates of complications from infusing vasopressors through PIV are low.
A meta-analysis from the Journal of Emergency Medicine, which included 9 studies and a total of 1835 patients, showed that the prevalence of complications was .086 (95%CI 0.031–0.21). Out of the 122 (7%) complications that were identified, 117 (96%) of them were minor adverse events, such as phlebitis or erythema. Studies that provided safety guidelines, such as size of catheters and catheter location, had a even lower incidence of adverse events.
A post-hoc analysis of the ARISE trial revealed that time to initiate vasopressors was significantly shorter when using a PIV (2.4 vs. 4.9 hours, p < 0.001), and vasopressor administration via PIV was not associated with increased mortality.
In summary, the risk of complications from vasopressor infusion via PIV is far less common than previously thought. More prospective, controlled trials are needed to elucidate potential patient risk factors for adverse events, and the effects of vasopressor concentration or infusion time on PIV administration complications.
To administer vasopressors through PIV route, use 20-gauge or larger catheters to cannulate larger peripheral veins (antecubital fossa, upper arm brachial or cephalic vein). Monitor PIV function every 1 or 2 hours until vasopressor route is switched to CVC administration.
Written by:
Clara, PharmD
Pharmacy Resident, PGY-1
Reviewed By:
Joanne C. Routsolias, PharmD, RN, BCPS
Clinical PharmD Specialist - Emergency Medicine/Toxicology
References
Delaney, A., Finnis, M., Bellomo, R., Udy, A., Jones, D., Keijzers, G., MacDonald, S., & Peake, S. (2020). Initiation of vasopressor infusions via peripheral versus central access in patients with early septic shock: A retrospective cohort study. EMA - Emergency Medicine Australasia, 32(2), 210–219. https://doi.org/10.1111/1742-6723.13394
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Medicine, 47(11), 181–1247. https://doi.org/10.1007/s00134-021-06506-y
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. EMA - Emergency Medicine Australasia, 32(2), 220–227. https://doi.org/10.1111/1742-6723.13406
Tran, Q. K., Mester, G., Bzhilyanskaya, V., Afridi, L. Z., Andhavarapu, S., Alam, Z., Widjaja, A., Andersen, B., Matta, A., & Pourmand, A. (2020). Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis. In American Journal of Emergency Medicine (Vol. 38, Issue 11, pp. 2434–2443). W.B. Saunders. https://doi.org/10.1016/j.ajem.2020.09.047