I have quite a love-hate relationship with central lines. They sometimes give me the warm and fuzzies when my Emergency Medicine colleagues call me for a sick patient in the ED who is entirely appropriate for the ICU. I see a right internal jugular central venous catheter on the chest x-ray. In my practice, I receive a secure message via a text message-like app from emergency department staff with the patient’s medical record number and other details.
I take this medical record number and quickly review the patient’s chart before speaking to the emergency medicine physician. The 30 seconds that I take reviewing the chart provides excellent insight as to why I am being called in the first place. If they’re sick-sick and needed, it should be there, and we have no reason to contemplate peripheral vasopressors. I want you to know that a well-tucked-in patient is much appreciated upstairs in the ICU. My initial thought is, oh good, this means that I don’t have to do it. But sometimes, patients are not as clear-cut. Or perhaps we can get them over the hump without dropping a central line and trying peripheral vasopressors. If you need to learn what vasopressors are or want to learn more about them, CLICK HERE.
Full disclosure: I am compensated for placing central lines. The average Medicare reimbursement for a central line in 2021 is $85.49. However, I am advocating against placing central lines and attempting to utilize peripheral vasopressors in some cases. It’s all about choosing what is best for the patient.
My first publication was actually on peripheral vasopressors. I worked with the great Dr. Sudhir Datar when I was in fellowship, and he encouraged me to look into our utilization of peripheral phenylephrine. It was a gratifying project, and we have been cited 13 times since it was published in 2017. Despite its limitations, such as being a retrospective analysis, we are pretty proud of it. It is also not open-access, unfortunately. I wish I could share it with more people. We concluded from our findings that the “infusion of phenylephrine through PIV is safe when used in moderate doses for a short time and can be considered instead of placing a central line solely for this purpose.”
You see, there’s a lot of time, energy, and resources that go into placing a central line. This includes the cost of the central line kit and all the necessary accessories to go through the procedure. In addition, placing the line itself takes a certain amount of time depending on factors such as anatomy, skill set, and assistance in setting up. The time clinicians spend placing the central line is coupled with a similar amount of time by the bedside nurse, who is usually around to assist. Therefore, this is more than just a physician or an APP ordeal.
Let’s not forget the most critical component, though, and that is the patient. Just discussing that you might be sticking a large needle and a catheter in their neck, groin, or chest brings significant concern. Sometimes, we premedicate our patients as their anxiety is through the roof. I playfully make a pact with certain patients who can communicate that if they feel any discomfort, they will be allowed to punch me. So far, I have not been punched. I tend to be quite generous with the lidocaine.
That being said, numerous complications could occur in the placement of the central venous catheter. The data presented in the article we will review states that up to 2.1% of patients experienced significant mechanical complications such as a pneumothorax. 0.5 to 1.4% had symptomatic DVT. 0.5 to 1.4% of patients experienced bloodstream infections. Considering all the central lines we place in our respective practices, these are definitely not numbers that one could ignore.
The paper I am using as a citation for this post was published just a few days ago, on April 16th, 2021. It is titled “Adverse Events Associated with administration of vasopressor medications through a Peripheral Intravenous Catheter: a systematic review and Meta-analysis.” Read the study for yourself, and do not trust me. Let’s get the limitations out of the way first. They analyzed 14 studies, of which only two were randomized trials. It’s also challenging to compare phenylephrine versus norepinephrine as they have different pHs. Defining an adverse reaction or whether it was reported correctly during the chart review is also problematic.
In the paper I helped write, I recall collaborating with my colleagues to figure out numerous variables we would all be curious about. These include the location of the peripheral IV in sorting out whether it was in the proximal upper extremity, wrist, or hand. We also considered the different sizes of the peripheral IVs regarding the gauge. Which size would be optimal? A 16, 18, 20, or 22?
It was easy for us because we were only looking at phenylephrine. Still, one has to consider the differences between dopamine, epinephrine, norepinephrine, phenylephrine, and vasopressin, and now we are still trying to figure out what to do with Giapreza (Angiotensin II). Then, one has to consider the maximum rate of infusion and the total duration of information. Lastly, one has to evaluate how you are going to define complications. That said, it is easy to see what a pain in the butt doing one of the studies could be.
All in all, the authors looked over 23 studies that included adults and children with more than 16,000 patients. They found that the incidence of adverse events was just 1.8% in adults, defined as low incidence. A bit of insight here is that most of the studies used 20 gauge IVs or larger in veins that are proximal to the hands. The authors state, and I agree, that we need additional high-quality research. The caveat to this is, knowing how cumbersome and complicated collecting and analyzing these could be, I find it hard-pressed that someone will do it prospectively anytime soon.
First of all, you cannot blind the nurses and physicians as to where the patient is being provided with their peripheral vasopressors. Also, could you imagine obtaining consent from the patient to be in the peripheral vasopressors group? You told them, “There may be a small chance that your arm will fall off.” That is a joke, but you get what I mean. What I mean when I say, “Your arm will fall off,” is that there might be limb ischemia or tissue necrosis.
So, the next logical question is self-reflection, asking what I do in my practice. I have been using peripheral vasopressors for years and have had zero complications. I use only phenylephrine and norepinephrine through the peripheral IVs. You need a central line if you need to be on more than 10mcg/min of norepinephrine. If your vasopressor doses are increasing quickly, you need a central line. The other caveat is that you need a central line if you’re on peripheral vasopressors for more than 24 hours.
I have made exceptions to these points when, say, a terminally ill patient is just waiting for a family member to arrive from out of town to say goodbye. For the most part, we’re all good with them at my shop. We try to use 20 gauge IVs proximal to the hands, and there’s a checklist that the nurses have to evaluate to see if the IV meets the criteria for being viable for peripheral vasopressors. This includes a lack of resistance, good pullback, etc. If the patient even hints that the IV burns, we’re stopping. Patient safety comes first. How to deal with extravasation injuries is something other than what I am going to touch on in this post. I hope this is all helpful!
Citations for Peripheral Vasopressors
Owen VS, Rosgen BK, Cherak SJ, Ferland A, Stelfox HT, Fiest KM, Niven DJ. Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis. Crit Care. 2021 Apr 16;25(1):146. doi: 10.1186/s13054-021-03553-1. PMID: 33863361.
Link to Article
Link to FULL FREE PDF
New Article from 8/26/22
Araiza A, Duran M, Varon J. Administration of vasopressors through peripheral venous catheters. CMAJ. 2022 May 30;194(21):E739. doi: 10.1503/cmaj.211966. PMID: 35636752; PMCID: PMC9259422.
Link to Article
Link to FULL FREE PDF
My Published Work on the Topic:
Datar S, Gutierrez E, Schertz A, Vachharajani V. Safety of Phenylephrine Infusion Through Peripheral Intravenous Catheter in the Neurological Intensive Care Unit. J Intensive Care Med. 2018 Oct;33(10):589-592. doi: 10.1177/0885066617712214. Epub 2017 Jun 1. PMID: 28569131.
Link to NOT FREE Article
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