Peripheral Vasopressors: Are They Safe for our Patients?

I have quite the love-hate relationship with central lines. They sometimes give me the warm and fuzzies when my Emergency Medicine colleagues call me for a borderline sick patient in the ED who is completely appropriate for the ICU and 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 staff in the emergency department with the medical record number of the patient and some other details. I take this medical record number and quickly review the chart of the patient prior to speaking to the emergency medicine physician. The 30 seconds that I take reviewing the chart provides great insight as to why I am being called in the first place. If they’re sick-sick and it’s needed, well, that means it should be there and we have no reason to contemplate peripheral vasopressors. 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 do not know 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. But I am advocating against placing central lines and attempting the utilization of 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 very rewarding project and we have been cited 13 times since it was published in 2017. We are quite proud of it despite it having limitations such as it being a retrospective analysis. 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 in lieu of placing a central line solely for this purpose”.

You see, there’s a lot of time and energy as well as 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, assistance in setting up. The time that clinicians spend placing central lines is usually coupled by a similar amount of time spent by the bedside nurse. Therefore, this is not just a physician or an APP ordeal. Let’s not forget the most important component, though and that is the patient. Just discussing the fact that you might be sticking a large needle and a catheter in their neck, groin, or chest brings a significant amount of concern. Sometimes we need to premedicate our patients as their anxiety is through the roof. I playfully make a pact with certain patients who are able to communicate that if they feel any discomfort that 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, there are numerous complications that could take place in the placement of the central venous catheter. The data presented in the article we are going to be reviewing states that up to 2.1% of patients experienced significant mechanical complications such as a pneumothorax. 0.5 to 1.4% had symptomatic DVT’s. 0.5 to 1.4% of patients experienced bloodstream infections. These are definitely not numbers that one could ignore considering all the central lines we place in our respective practices.

The paper that 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, say, phenylephrine versus norepinephrine as they have different pH’s. It’s also challenging to define what an adverse reaction really is or if it was even reported correctly when performing the chart review. In the paper that I helped write I recall collaborating with my colleagues to figure out numerous variables that 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 with regards to the gauge. We have to wonder which size would be optimal? A 16, 18, 20, or 22? It was easy for us because we were only looking at phenylephrine but one has to consider the differences between dopamine, epinephrine, norepinephrine, phenylephrine, vasopressin and now we have no clue what to do with Giapreza (Angiotensin II). Then one has to consider the maximum rate of infusion as well as the total duration of infusion. Lastly one has to evaluate how you are going to define complications. That being 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 both adults and children with a total of more than 16,000 patients. What they found, was that the incidence of adverse events was just 1.8% in adults which is defined as low incidence. A bit of insight here is that most of the studies used 20 gauge IV’s or larger in veins that are proximal to the hands. The authors do state and I definitely 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 as well as the physicians as to where the patient is being provided with their peripheral vasopressors. In addition, imagine obtaining consent from the patience to be in the peripheral vasopressors group. You were saying to them “there may be a small chance that your arm will fall off”. That is obviously a joke but you get what I mean. What I really 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 some self reflection asking what I do in my practice. I have been using peripheral vasopressors for years and thankfully have had zero complications. I try to use only phenylephrine and norepinephrine through the peripheral IV’s. If you need to be on more than 10mcg/min of norepinephrine, you need a central line. If your vasopressor doses are increasing quickly, you need a central line. The other caveat is that if you’re on peripheral vasopressors for more than 24 hours, you need a central line. I have made exceptions to these points at times when, say, there’s a terminally ill patient who is just waiting for a family member to arrive from out to town to say goodbye. For the most part, we’re all good with them at my shop. We try to use 20 gauge IV’s proximal to the hands and there’s a checklist that the nurses have to evaluate to see if the IV meets 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 not something I am going to touch on in this post. Hope this is all helpful!

https://youtu.be/MX_EgIwvAOo

BILLING CODES FOR CRITICAL CARE REFERENCE (2019)
BILLING CODES FOR CENTRAL LINES (2021)

Citations:
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

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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