Podcast 107 – Peripheral Vasopressor Infusions and Extravasation

extrav

This episode was inspired by an article that Mike “the Rock” Stone asked me to take a look at:

Central or Peripheral Catheters for Initial Venous Access of ICU Patients: A Randomized Controlled Trial by Ricard JD et al. (23782969)

In this interesting RCT, patients were randomized to either peripheral or central access. The study was analyzed by intention-to-treat, meaning if the pts in the peripheral group got central access, the complications were still assigned to the peripheral group. While the results listed less major complications with central rather than peripheral access (0.64 vs. 1.04, p<0.02), that is not the whole story.

A majority of the complications in the PIV group were actually the inability to insert a PIV. The other complications seem to the same in both groups. But what about what we really want to know…were there extravastion injuries in the PIV group. They did not exclude patients on vasopressors until they were on very high doses (e.g. >33.3 mcg/min of norepinephrine), so this study can actually give us some answers. There were 19 pts in the PIV group with the major complication of subcutaneous diffusion (i.e. extravasation). Neither the original study nor the supplemental material listed the severity and needed treatment for these extrav. injuries. I therefore wrote to the author who graciously replied. None of these patients required anything more than observation and conservative management.

So can we use peripheral lines for vasopressors? Folks like my friend Paul Mayo would say, “yes!” In his unit, pts are getting peripheral or mid lines almost exclusively. Rob Green, a Canadian resuscitationist, was also working on this topic last time I spoke with him.

But vasopressors can cause problems in Extravasation

I’m not going to bother to list the data on norepi, b/c everyone is already familiar and fearful with that drug peripherally.

Dopamine Extravasation

(9606475)

Vasopressin Extravasation

(12163813) (16505698)

Have not found any evidence for phenylephrine problems, but I’m sure there is some out there (though I think it is the safest agent)

IO is not a panacea

Extravasation may result from misplacement/dislodgement and in rare cases even Compartment Syndrome. IOs (and probably IVs) can be confirmed by ultrasound with a squeeze test [PMID 24036195]

Push-Dose Pressors

You should also check out the Push-Dose Pressor Episode for another option in these situations.

Extravasation Injuries from Vasopressors

Prevention

  • Avoid the hand/wrist (and maybe the AC fossa)
  • Avoid Ultrasound-Guided IVs that are Crappy
  • Avoid Crappy IVs in general
  • You need a protocolized extremity check
  • You need the antidotes and a worksheet in the room with the patient.
  • 10 mg of Phentolamine Mesylate can be added to each liter of solution containing norepinephrine. The pressor effect of norepinephrine is not affected. (13788877)

Treatment

PHE lgStep I

If the pt is relying on the agent for their hemodynamics, switch the pressor to another IV or place an immediate IO or central line.

Step II

Do not pull the cannula yet

Step III

Suck out as much as you can

Step IV

Administer subcutaneous phentolamine mesylate (Regitine) using 25 G or smaller needle

Comes in 5 mg per 1 ml vials. Place in 9 ml of NS

A dose of 0.1 to 0.2 mg/kg (up to a maximum of 10 mg) should then be injected through the catheter and subcutaneously around the site.

Administered as soon as the extravasation is detected, even if the area initially looks just a little white or OK.

Should see near immediate effects; otherwise consider additional dose. Now pull the catheter.

May cause systemic hypotension (but they should be on pressors at another site)

Step V

Consult Plastics

Evidence for Phentolamine

(13362728),(13415911),(13488384),(13606129)

Other, Non-Vasopressor agents

Extravasation Flush-out Technique

  • Dilute Hyaluronidase will be used to flush out the drug.
  • Take one vial and dilute it so that you have 150 units of drug in 1 ml of saline
  • Dose is 1-2 ml (most sources say 1 ml)
  • Numb the area with lidocaine (obvious without the epi)
  • Inject the drug with a 25 G or smaller needle, in 5 separate areas into the edges of the affected area. I give 1 of them through the original cannula if it has not been removed.
  • Make 4 stab wounds at the points of the compass.
  • Through one of them, insert a cannula, perferably one of the ones used for liposuction (blunt ended, with side holes)
  • Flush 500 ml of NS through the wound
  • Consult plastics for further management
(2358898) and (12055433)

and http://www.extravasation.org.uk/home.html

Here is a great cheat sheet on the treatment of extravasation from The University of Kansas Hospital

SMACC Registration is Now Open!!!

Now on to the Podcast…

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Comments

  1. Mary Shue says:

    This may be the norepinephrine with phentolamine article you were looking for:
    http://circ.ahajournals.org/content/22/5/935.full.pdf

  2. Hello Scott,

    as always i enjoyed your show. My problem is following. In Germany you can´t get Phentolamine. Do you have any suggestions what to use instead?
    Looking forward to hear your answer
    Volker

  3. I have used the long catheter from the central line kit as a quasi-central line in the brachial artery for pressors or IV access. These seems to work better than the US guided long catheters and not does blow as you mentioned in the podcast

  4. Rick Janik says:

    Scott,

    Can you share your comments on use of an easily placed catheter in the saphenous or EJ vein for peripheral vasopressors? How about a line from a cutdown? These sites seem common during difficult access especially before the era of US guided access.

    Thanks Rick

  5. What about iv contrast extravasation

    • wish i knew. some sources say cold, some say warm compresses. I have no idea, but the contrast is isontonic, so it should not cause direct injury.

  6. Sounds like an incredibly low risk, maybe that risk is actually lower than the complication rate from central lines. Also it seems strange that you can give a medication im or subcutaneous without problems and then have to worry about extravisation.

  7. What level of sterility would you suggest with midlines? Something about doing seldinger technique without full garb seems wrong to me. At the same time, I can’t imagine the infection rate would differ much from US guided long PIVs.

  8. Marc Mobey says:

    Hey Scott.
    Up here in Alberta we routinely run Epi, and Dopamine, and occasionally Norepinephrine in the out of hospital setting through I.V’s started in the field. Without access to phentolamine, it occurred to me a thin smear of Nitropaste, or perhaps a short duration placement of a Nitropatch may achieve temporizing treatment until a hospital can be accessed.
    The trick would be preventing a hypotensive event, but that just emphasises your step #1…. re-establish the pressor.
    Thanks

    • Marc Mobey says:

      Forgot to add: I couldn’t find any literature on the use of Nitro for this, however, anecdotally (Back in the day) I have seen a spray of nitro shot onto the arm, then quickly wiped off to aid in locating a vein for IV placement. I don’t know if it actually works physiologically.

    • there is literature for the topical nitro-paste in this circumstance; not great literature, but worth a try until they get in-house.

      • Hi All-

        In our ICU’s in Calgary when we have no cental access we will infuse norepi peripherally. Our policy is to keep IV site visible @ all time and document Q15M. Peripheral infusion is not considered ideal and we aim to have a central line in ASAP- Thanks for the article.

  9. Alonso Miguel says:

    Hey Scott!

    Do you know of any good study that directly compares norepi vs dopamine via peripheral lines?
    I’d love to show some good evidence to a critical care resident I work with…

  10. Hi Scott,

    You mentioned that peripheral lines could be exchanged using a pediatric IJ kit or a femoral a-line kit…do you use catheters in those kits as the midline or do you use a catheter that is purchased separately?

    Thanks and keep up the fantastic work!

  11. Michael says:

    Hi Scott,

    Long time listener first time caller…..

    I think peripheral vasopressors make so much sense. Especially for those patients who need some short term support but are likely to be sorted in a few hours. It frustrates me that if I am hung up with something else that a patient has to remain hypotensive till I can place a CVC. It’s dumb.

    My main thoughts are:

    1. If a patient is clearly going to require a CVC I think peripheral pressor for a short time while a CVC is placed is sensible but prolonged infusion probably offers no benefit with all the risks. Predicting who will definitely require a CVC (ie. remain pressor-dependant more than a few hours) being the issue.

    2. At the places where I work convenience sometimes results in neglect. I wonder if running the pressor peripherally will sometimes result in less attention to the patient, resuscitation, diagnosis and the need for a doctor senior enough to place a CVC to actually see the patient.

    3. Do you dilute your pressor down? My feeling is to put 6mg in 1L rather than 100ml just so the numbers are easy for everyone. If that degree of extra volume concerns anyone then that is not a patient who should be having periph pressor anyway in my mind except in the ultra-short term. They didn’t mention their dilutions in the study, as I could see, or the numbers that were placed for norepi vs epi, amio, Vanc.

    4. Do you routinely make sure the midline catheters get removed before going to the ward or that they are removed early in ICU re-infection unless totally aseptic and positioned well? I have no problem with them but find them as time-consuming as a CVC and unless folk are happy to use them without an x-ray there is still a big delay in starting pressors. I don’t think an XR is needed if it aspirates blood and I have ultrasounded placement in a vein but I can see nursing staff stamping feet and insisting here in Oz…..
    I think I’d use a single lumen paediatric CVC < 24hrs (either through existing IV after US to make sure venous or new stab) just to avoid having to get past the axilla where i often get stuck particularly in the cephalic. No-one lets me use periph pressor so I am talking out my ass tbh. I think the more distance between vein insertion and catheter tip the better.

    Love your work.

    • Michael,

      Great comments. If I’m going to leave in the mid, it will only be if done full sterile. I agree with number 2. Pts on pressors should be in high intensity care regardless of the route.

  12. another long time listener ……first time caller….love your blog……im an emergency physician from malaysia…..in my place we usually put norepi through big external jugular vein with 16 or 14g needle…..seems to work well with no extravasation……whats u think…..thanks…

  13. Scott. Thanks for the great episode. Just wondering if you or anyone else is regularly using mid line catheters in the ED for vasopressors. We looked at bringing some in to our ED but were refused by the P&T committee because the mid line product monograms stated they should not be used for infusions of meds with ph less than 5. (Levophed is 3-4). Wondering if anyone else has run up against this.

    • Wow that is baffling. I don’t imagine the problem would be the catheter dissolving. Which company and product?

      • The reason may not be in regards to catheter dissolving. Rather, the concern is for infiltration/extravasation that would only be noticed after significant tissue damage is done since the line is in deeper. On the flip side, I can’t recall ever seeing one of these lines blow…don’t know the data behind this though.

        • doesn’t follow. the monogram mentioned is not discussing vessicants, but specifically low pH. Not sure why they would separate the drugs like that. Many drugs with normal pH are very dangerous in extrav.

  14. Scott- would be interested to hear your opinion…

    http://www.ncbi.nlm.nih.gov/pubmed/22579025

    • I would be worried about how much cannula remains IV and dislodgement. Don’t know what they used in this series.
      Ext jug maybe but I’d still be nervy…. Useful for an absolute emergency sometimes but not for hours.
      Maybe the long cannula that comes with some CVC’s but may as well don some gloves/gown pop the wire down and make it the real deal I’d have thought except in a crisis.

      • Agree with Michael. I guess they are using this when I would use IO. Seems like if you are going to access the central circulation, you should just do a sterile central line and protect the pt.

        • The link to the PDF for the actual paper is below… they discuss all the concerns you both have.

          1. They used 2 or 2.5 inch 14 or 18 gauge needles. That is plenty of catheter and I would not be concerned about dislodgement …

          2. From the paper- “we consider this line a temporary solution and do not recommend that is serve as definitive access”

          3. Scott- your sterility concern is very well addressed in the paper as well and they have a compelling argument. This is not a central line. It remains as far away from the SVC/RA junction as an EJ, which drains into the subclavian as does the IJ. Are you gowning, draping, and masking for your EJ’s?

          I would say that first all, that I don’t see any reason why this can’t remain definitive access. 5 of the 9 pts in their group had the line in until discharge, whereas I certainly would not leave an I/O in throughout the admission. But that issue aside, with a little practice you can pop in an u/s -guided 14 gauge in an IJ during resusc in like 2 seconds, and now you have a much “more central”, much larger bore than an I/O all the way down in the tibia, with a far superior flow rate (I/O probably doesn’t exceed that of a 21 gauge peripheral catheter)

          Maybe not quite ready for prime time- but my guess is that it will be in the near future.

          http://www.emergencyultrasoundteaching.com/assets/articles/vascaccess_2012_Teismann_JEM.pdf

  15. why should you do that if you are going to stab the IG? put a proper one in!

  16. Walter rustmann says:

    Love the podcasts and SMACC. Trying to get approval for nursing placement of PICC’s in the ICU and midlines. Our plan is to use them for pressors and other ACLS meds as needed. One stumbling block I am coming up against is that some of the midcath information states they are contraindicated for caustic agents or pressors. I thought your podcast actually favored their use for this. Do you have literatuer or articles to support their use
    Wally Rustmann/ Intensivist/ San Angelo Texas

    • i have only the data on using peripheral lines, which is directly extrapolatable I think. There is nothing intrinsic to pressors that dissolves catheters. That doesn’t mean your hospital will agree, of course.

Trackbacks

  1. […] on epinephrine 5 mcg/min via 18G antecubital peripheral IV (Are peripheral pressors safe? See EMCrit Episode 107 for more),  instead of starting with transcutaneous pacing. Minutes later his HR is 22 and BP […]

  2. […] EMCrit Podcast 107 – Peripheral Vasopressor Infusions and Extravasation […]

  3. […] – note the benign outcomes for the 19 cases of extravasation was confirmed in personal correspondence from the author to Dr Scott Weingart. More on this topic on emcrit […]

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