Peripheral administration of norepinephrine
Abstract:
Background: Historically, norepinephrine has been administered through a central venous catheter (CVC) due to concerns about the risk of ischemic tissue injury if extravasation from a peripheral intravenous catheter (PIV) occurs. Recently, several reports have suggested that peripheral administration of norepinephrine may be safe.
Research question: Can a protocol for peripheral norepinephrine administration safely reduce CVC days and CVC placement?
Study design and methods: This was a prospective observational cohort study conducted in the medical ICU at a quaternary care academic medical center. A protocol for peripheral norepinephrine administration was developed and implemented in the medical ICU at the study site. The protocol was recommended for use in patients that met pre-specified criteria but was used at the treating clinician’s discretion. All adult patients admitted to the medical ICU receiving norepinephrine through a peripheral intravenous catheter from February 2019 to June 2021 were included.
Results: The primary outcome was the number of CVC days avoided per patient, and the secondary safety outcomes included the incidence of extravasation events. 635 patients received peripherally administered norepinephrine. The median CVC days avoided per patient was 1 (IQR 0, 2 days per patient). Of the 603 patients who received norepinephrine peripherally as their first norepinephrine exposure, 311 (51.6%) never required CVC insertion. Extravasation of norepinephrine occurred in 35 patients (75.8 events [95% CI 52.8, 105.4] per 1000 PIV infusion days). Most extravasations caused no or minimal tissue injury. No patient required surgical intervention.
Interpretation: This study suggests that implementing a protocol for peripheral administration of norepinephrine can safely avoid one CVC day in the average patient with 51.6% of patients not requiring CVC insertion. No patient experienced significant ischemic tissue injury with the utilized protocol. These data support performance of a randomized prospective multicenter study to characterize the net benefits of peripheral norepinephrine administration compared to norepinephrine administration through a CVC.
Reference:
Yerke JR, Mireles-Cabodevila E, Chen AY, Bass SN, Reddy AJ, Bauer SR, Kokoczka L, Dugar S, Moghekar A. Peripheral administration of norepinephrine: a prospective observational study. Chest. 2023 Aug 21:S0012-3692(23)05350-3. doi: 10.1016/j.chest.2023.08.019. Epub ahead of print. PMID: 37611862.