Peripheral intravenous norepinephrine safe at low doses for <24 hours

It is safe to administer norepinephrine through a peripheral intravenous catheter (PIV) at low doses for <24 hours using a protocol, suggests a study. Preventing the unnecessary insertion of central venous catheter (CVC) helps minimize the risk of central line complications, thus improving patient morbidity.

“Practitioners should still use clinical decision making to identify patients in which peripheral vasopressor administration is appropriate and frequently reassess the patient’s condition with escalation to CVC placement if the patient’s condition worsens,” the researchers said.

In this single-centre, prospective, observational study, a protocol was created for peripheral administration. The researchers then evaluated the safety, CVC placement, and adherence with protocol elements among patients receiving norepinephrine in the medical intensive care unit (MICU).

Patients were considered for PIV administration of low-dose norepinephrine for <24 hours based on clinical status and anticipated short-term use. Protocolized interventions for PIVs were as follows: criteria for gauge, number, and site as well as visual inspection and evaluation every 2 hours. The researchers collected data on protocol elements for assessment.

A total of 316 norepinephrine infusions were made, of which 92 were through PIV. Some patients may have had received several treatments, according to the researchers. [J Pharm Pract 2022;35:347-351]

Of the 92 infusions, 31 (34 percent) did not require CVC. Three had infiltrated PIVs with no tissue injury. Maximum dose was 73 percent, and majority of the infusions (97 percent) took <24 hours.

Nursing adherence included 91 percent gauge, 65 percent proper site, 99 percent adequate number, 49 percent blood returns on initiation, 55 percent ongoing blood return, and 61 percent IV site checked.

These findings supported those of several other published studies that have retrospectively assessed the administration of vasopressors via PIV. [J Emer Med 2018;54:47-53; J Int Care Med 2017;1:1-8; J Int Care Med 2018;33:589-592; J Crit Care 2016;34:107-110]

“Implementation of the protocol in our patients, was not only demonstrated to be safe, but importantly decreased the need for central line placement in 34 percent of occurrences for patients who met criteria for peripheral administration,” the researchers said.

“Although central line placement may be necessary to safely administer certain treatments or interventions, they also place patients at additional risks for complications including infection, thrombosis, hematoma, obstruction, and dislodgment,” they added. [Crit Care Med 2007;35:1390-1396]

Incidence of complications ranged from 5 to 15 percent. In most severe cases, such complications could result in patient death. [Crit Care Med 2018;46:1998-2009; Crit Care Med 2007;35:1390-1396]

Over the past decade, components of early-goal resuscitation had been re-evaluated, thus central lines were not anymore a necessity for sepsis resuscitation. [Crit Care Med 2017;45:486-552]

“Therefore, in the MICU patient population, central lines may be placed solely for vasopressor administration even in patients with short vasopressor duration following early identification and resuscitation in those units without a protocol for safe peripheral administration,” the researchers said.