Pearl #1: Use Proximal Veins
- Use veins in the antecubital fossa or more proximal
- These are larger veins which allow for larger IVs and decrease the chances of puncturing the back wall of the vein
- Go with the biggest most superficial vein so that we don’t conceal extravasation in deeper veins
- Not all of these IVs will be US-guided, but for deeper veins will need to use sterile technique with a linear probe
Pearl #2: Use an Ultralong Catheter
- IV catheters come in varying lengths, including:
- Standard: 2.95cm (1.16in)
- Long: 4.78cm (1.88in)
- Ultralong: 6.35cm (2.5in)
- If we are using more proximal veins, then we have more subq tissue to traverse. Therefore, we want to ensure the catheter we use is able to get >2.75cm into the vein [3] to avoid the catheter coming out. In some cases a long catheter (4.78cm) may be more than enough
Pearl #3: Limit the Time of Infusion
- Peripheral vasopressors should be considered a bridge to somewhere…
- The patient improves, in which case you can stop the infusion
- The patient doesn’t improve in which case you should insert a midline or CVC
- The longer you run this infusion, the more chance of extravasation. According to my interpretation of the literature, the longest we should be running these infusions peripherally is 4hrs
Pearl #4: Use a Dilute Concentration + Small Volume
- Norepinephrine comes in 4mg, 8mg, and 16mg doses. Use the smallest dose which is 4mg
- You can mix the norepinephrine in a variety of fluids. This does not matter as much as the volume you mix it in (This should be 250mL)
Pearl #5: Have an Observation Protocol
- Once you have started an infusion through a peripheral IV, someone should be physically visualizing the site q15 to q30min. This ensures that if extravasation occurs it is as small a volume as possible to avoid ischemia and necrosis of the extremity
Pearl #6: Have an Extravasation Protocol [3]
- If extravasation occurs, stop the infusion and switch it to a different line
- Leave the catheter in place
- Suck out as much as you can from the catheter
- Use Phentolamine or Terbutaline (Whichever you have available):
- Phentolamine
- 5mg/mL x2 in 8mL of NS (Max 10mg)
- Inject 5mL through catheter
- Inject remaining 5mL in the subq tissue (Around area of blanching)
- Unclear what time frame is optimal for re-dosing (Typically wait 1hr)
- Terbutaline
- 1mg/mL in 9mL of NS
- Inject 5mal through catheter
- Inject remaining 5mL in the subq tissue (Around area of blanching)
- Can repeat every 15min as needed
- Nitroglycerin
- Apply 1inch of topical paste to the affected area
- Can repeat every 8 hours
- Elevate the extremity
- Use warm compress (Be careful to not burn the skin)
- Phentolamine
Clinical Bottom Line:
- Use an antecubital fossa or more proximal vein (Larger diameter)
- Use an ultralong catheter (6.35cm or 2.5in — >2.5cm in the vein)
- Do not run infusions for >2 – 4hrs
- Use as dilute a concentration in as small a volume as possible (4mg/250mL)
- Have an IV observation protocol (q15 – q30min)
- Have an extravasation protocol (Phentolamine or Terbutaline + Topical NTG + Elevation + Warm Compress)
References:
- Tian DH et al. Safety of Peripheral Administration of Vasopressor Medications: A Systematic Review. EMA 2019. PMID: 31698544
- Pancaro C et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg 2019. PMID: 31569163
- Lewis T et al. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med 2019. PMID: 28073314
- Loubani OM et al. 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.PMID: 25669592
- Medlej K et al. Complications from Administration of Vasopressors Through Peripheral Venous Catheters: An Observational Study. JEM 2018. PMID: 29110979
Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami) and Mizuho Morrison, DO (Twitter: @mizuhomorrison)
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