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. [cite]23782969[/cite]
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
[cite]9606475[/cite]
Vasopressin Extravasation
[cite]12163813[/cite]
[cite]16505698[/cite]
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 can be added to each liter of solution containing norepinephrine. The pressor effect of norepinephrine is not affected. [cite]13788877[/cite]
Treatment
Step 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
[cite]13362728[/cite],[cite]13415911[/cite],[cite]13488384[/cite],[cite]13606129[/cite]
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
[cite]2358898[/cite] and [cite]12055433[/cite]
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
Additional New Information
- Loubani & Green published a systematic review of peripheral vasopressors (10.1016/j.jcrc.2015.01.014)
- Paul Mayo's group published the LIJ Experience
- A paper by Kamal Medlej., et al. “Complications from the Administration of Vasopressors through Peripheral Venous Catheters: An Observational Study” is pending publication
- Medlej K et al. Complications from Administration of Vasopressors Through Peripheral Venous Catheters: An Observational Study. JEM 2018. PMID: 29110979
- Safety of the Peripheral Administration of Vasopressor Agents https://doi.org/10.1177/0885066616686035
- A very large retrospective cohort in the operating room
- Systematic Review Demonstrates Safety (https://doi.org/10.1111/1742-6723.13406)
- Another Meta-Analysis Shows Safety (Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis. Am J Emerg Med. 2020 Sep 28;S0735-6757(20)30842-1. doi: 10.1016/j.ajem.2020.09.047.
Online ahead of print.) - Newest study on peripheral norerpi. 5.5% of extrav non-requiring any surgical intervention and considered minor. > 50% of pts avoided central lines.
More on EMCrit
Additional Resources
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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This may be the norepinephrine with phentolamine article you were looking for:
http://circ.ahajournals.org/content/22/5/935.full.pdf
That must be the one. Much thanks!
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
I would probably do the wash-out technique in that case.
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
I assume you mean one of the deep antecubital veins, not brach artery correct?
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
prob with ej is they often blow and it will be a while before you notice. Neither EJ nor saphenous seem like a temporizing solution.
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.
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.
usually turns out to be a concentration issue in meds like epi that we give subq all the time.
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.
great ?
i would say at the very least, gloves, mask, hat. I think a gown would be wise.
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
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.
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…
not sure why anyone would do that study. just show him or her the reports of dopamine extravasation.
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!
the catheters from the kits
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… Read more »
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.
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…
think it is cool unless it pulls out of the vein in which case not so cool and not easily recognized.
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.
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… Read more »
Sam, Can you do me a favor and sign your comments with your name and affiliation. Much thanks
why should you do that if you are going to stab the IG? put a proper one in!
sorry, no idea what this means
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.
Hi ~
Just picking up this thread. Can one insert a triple lumen CVC instead of a pediatric single lumen catheter? Thanks ~ Andrew
Do we know what concentation of pressors were used on this study?