Do Vasopressors Really Need a Central Line?

When it comes to vasopressor administration, hospital pharmacists are traditionally taught that it must be through central venous access, or a central line. This, of course, is meant to mitigate the risks of extravasation through peripheral venous access sites.

In many cases, the need for vasopressors occurs prior to the establishment of central access and peripheral administration of the drug. This risky practice gives pause to many pharmacists, particularly in the era of phentolamine shortages.

Now, new evidence is challenging the tried-and-true belief that peripheral administration must be avoided.

A systematic review of available evidence pertaining to the risk of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous (IV) catheters and central venous catheters was recently published in the Journal of Critical Care. The authors searched Medline, Embase, and Cochrane databases for reports meeting their inclusion criteria.

Of the 85 articles included in this study, 270 patients and 325 events of local tissue injury and extravasation occurred.

Breaking down these events further, the authors noted that the vast majority of events occurred in patients receiving vasopressors through peripheral IV sites (318/325 events). Local tissue injury accounted for 204 of these events, and extravasation for 114 events.

The events generally did not cause major disability, as they occurred in fewer than 5% of cases, with mortality occurring in fewer than 2.2% of cases.

Among local tissue injury events, however, 85.3% occurred because peripheral IVs were distal to the antecubital or popliteal fossae (eg, hands, forearms, feet), and 96.8% occurred after 4 hours of infusion.

Similar findings were observed when extravasation occurred, as 75% of related adverse events were distal to the antecubital and popliteal fossae.

Because a systematic review methodology was used in this study, these results may not be a slam dunk in approving widespread use of vasopressors in peripheral IVs. Given this context, however, the use of vasopressors in peripheral lines for a short time (less than 4 hours) in IV sites in the antecubital fossae or further proximal could be considered in certain patients where a central line has yet to be placed and the risk of delaying therapy is high.

Reference

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;30(3):653.e9-e17.