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.
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]
You should also check out the Push-Dose Pressor Episode for another option in these situations.
Extravasation Injuries from Vasopressors
- 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]
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.
Do not pull the cannula yet
Suck out as much as you can
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)
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
Here is a great cheat sheet on the treatment of extravasation from The University of Kansas Hospital
- 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)
Now on to the Podcast…
- EMCrit Wee – Stop Kneejerk Intubation with the EMCrit Crew - March 30, 2020
- EMCrit Wee – Alternatives to Vent Splitting and the Safest Vent Splitting Methods in COVID19 - March 28, 2020
- COVID Airway Management Thoughts - March 27, 2020