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    Peripheral Vasopressors

    Cardinal Presentations / Presenting Problems, Cardiovascular, Critical Care / Resuscitation

    Last Reviewed on Feb 03, 2024
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    • Norepinephrine is a first-line agent to treat hypotension in patients with septic shock.  Despite this, and the robust body of evidence showing that delays in vasopressor initiation are associated with worse clinical outcomes, a recent large scale Canadian study demonstrated a continued hesitancy and reduction in the use first-line vasopressors to treat shock for reasons largely due to the absence of a central venous catheter (CVC).12   This is problematic because for many reasons, CVCs are often delayed or deferred in clinical practice, which therefore creates treatment delays and erodes our aforementioned time-to-treatment paradigm.
    • Administration of peripheral vasopressors (PVPs) leads to quicker vasopressor initation,1,12 and is as a safe and efficacious option that can help abate CVC-related delays.  Large-scale, high-quality studies are demonstrating utility and safety;1,5-12 the ED literature is beginning to replicate previous results;1,4,9,10,12,14 and PVPs are now included in the Surviving Sepsis Guidelines as a conditional recommendation to avoid unnecessary treatment delays in patients with septic shock.15

    Recommended Treatment

    • Norepinephrine has the most evidence when used as a PVP, while vasopressin and epinephrine have been studied the least.1,3-9,12
    • Extravasation events and complications are both uncommon and similar to those in patients with CVCs.1-4,6
      • Pooled extravasation rates are estimated between 0.035% to 5%.1-10
      • The most recent systematic view suggests a pooled adverse event rate of 1.8%.14
      • ED-specific extravasation rates appear to be similar, but data is limited.1,9,10
      • Almost all (95%) of extravasations seem to occur after >4hrs.2
    • Extravasation events do not result in significant injury and are unlikely to require medical or surgical intervention.1-10
      • No cases of ischemic necrosis have been reported.
    • They are safest when infused at, or proximal to, the antecubital fossa (ACF), and through larger bore IVs. 1-4,9,10
      • A systematic review showed that 85% of the reported complications were distal to the ACF.
    • The ideal or maximum PVP infusion duration is unclear1-5,9
    • PVPs result in expedited vasopressor initiation1,12 and are associated with improvements in processes of care including:
      • less overall vasopressor use.1
      • shorter durations of vasopressor administration.1,6,12
      • earlier administration of microbials.13
      • a modest reduction in the number of CVC days.1,6,7,12
      • a significant reduction in the number CVC insertions.6,7,12
      • minimal reductions in ICU length of stay.1,7
    • Their impact on patient outcomes is less clear:
      • PVPs were shown to be more likely to be used in sicker patients.13
      • Most patients who receive PVP initially receive a central line within a day.12
      • They do not seem to increase mortality.12,13
        • In a large multicenter retrospective cohort review looking at patients hospitalized with sepsis, there was no clear association between vasopressor route and patient mortality across multiple time points, mechanical ventilation, new dialysis, or length of hospitalization.12

    Quality Of Evidence?


    • PVP use in the ED is an option for treatment of hypotensive patients and can help avoid unnecessary treatment delays, but there continues to be a lack of high-quality evidence.
    • The most recent systematic review highlights the need for additional research examining the effects of PIV location and size, vasopressor type and dose, and patient characteristics to ensure the safety of PIV vasopressor administration.

    Related Information

    Reference List

    1. Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med. 2022;26(7):811-815. doi:10.5005/jp-journals-10071-24243

    2. 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. J Crit Care. 2015;30(3):653.e9-653.e6.53E17. doi:10.1016/j.jcrc.2015.01.014

    3. Tian DH, Smyth C, Keijzers G, et al. Safety of peripheral administration of vasopressor medications: A systematic review. Emerg Med Australas. 2020;32(2):220-227. doi:10.1111/1742-6723.13406

    4. Tran QK, Mester G, Bzhilyanskaya V, et al. Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis. Am J Emerg Med. 2020;38(11):2434-2443. doi:10.1016/j.ajem.2020.09.047

    5. Pancaro C, Shah N, Pasma W, et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg. 2020;131(4):1060-1065. doi:10.1213/ANE.0000000000004445

    6. Asher E, Karameh H, Nassar H, et al. Safety and Outcomes of Peripherally Administered Vasopressor Infusion in Patients Admitted with Shock to an Intensive Cardiac Care Unit-A Single-Center Prospective Study. J Clin Med. 2023;12(17):5734. Published 2023 Sep 3. doi:10.3390/jcm12175734

    7. Yerke JR, Mireles-Cabodevila E, Chen AY, et al. Peripheral Administration of Norepinephrine: A Prospective Observational Study. Chest. Published online August 21, 2023. doi:10.1016/j.chest.2023.08.019

    8. Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents. Journal of Intensive Care Medicine. 2019;34(1):26-33. doi:10.1177/0885066616686035

    9. Medlej K, Kazzi AA, El Hajj Chehade A, et al. Complications from Administration of Vasopressors Through Peripheral Venous Catheters: An Observational Study. J Emerg Med. 2018;54(1):47-53. doi:10.1016/j.jemermed.2017.09.007

    10. Nguyen TT, Surrey A, Barmaan B, Miller S, Oswalt A, Evans D, et al. Utilization and extravasation of peripheral norepinephrine in the emergency department. Am J Emerg Med 2021;39:55–59. DOI: 10.1016/j.ajem.2020.01.014.

    11. Munroe ES, Heath ME, Eteer M, et al. Use and outcomes of peripheral vasopressors in early sepsis-induced hypotension across Michigan hospitals: a retrospective cohort study. Chest. Published online October 26, 2023. doi:10.1016/j.chest.2023.10.027

    12. Teja B, Bosch NA, Wijeysundera DN, et al. First-Line Vasopressor Use in Septic Shock and Route of Administration: An Epidemiologic Study. Ann Am Thorac Soc. 2022;19(10):1713-1721. doi:10.1513/AnnalsATS.202203-222OC

    13. Delaney A, Finnis M, Bellomo R, et al. Initiation of vasopressor infusions via peripheral versus central access in patients with early septic shock: A retrospective cohort study. Emerg Med Australas. 2020;32(2):210-219. doi:10.1111/1742-6723.13394

    14. Owen VS, Rosgen BK, Cherak SJ, et al. Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis. Crit Care. 2021;25(1):146. Published 2021 Apr 16. doi:10.1186/s13054-021-03553-1

    15. Evans L, Rhodes A, Alhazzani A, Antonelli M, Coopersmith CM, French C, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Crit Care Med 2021;49(11):e1063–e1143. DOI: 10.1097/CCM.0000000000005337


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