Background: Vasopressors have historically been limited to central venous catheters (CVC) due to the risk of extravasation and subsequent tissue injury and necrosis with peripheral administration. However, CVC insertion is a time-consuming process associated with multiple complications. The Virginia Commonwealth University (VCU) Emergency Department (ED), a tertiary academic medical center, implemented a policy to allow for the administration of peripheral norepinephrine (NE). The policy limits the use of peripheral NE to a maximum dose of 20 mcg/min through an 18 gauge or larger antecubital or external jugular vein for a maximum of 4 hours. The objective of this study was to characterize the use and incidence of extravasation in all adult patients who received peripheral NE initiated in the VCU ED.
Methods: This was an observational, retrospective cohort study from March 2016 to November 2018. Adult patients who had orders for peripheral NE were screened and collected monthly during the study time frame. Of the 206 patients that were screened, 93 met inclusion criteria. Of those excluded, 65 never received peripheral NE, 22 had incomplete documentation, and 13 were pre-hospital cardiac arrests. Data were analyzed using descriptive statistics.
Results: Patients were 57.5 ± 16 years old and 52% male. A majority of patients received peripheral NE for distributive shock (63%). Eighty-seven percent received peripheral NE through an antecubital infusion site. The median duration of peripheral NE in the ED was 44 minutes (IQR 28, 89). Peripheral NE was continued outside of the protocol into the ICU in 19% of patients for an additional median of 169 minutes (IQR 68.5, 242). A central line was inserted in 87% of patients. Only 3 episodes of peripheral extravasation occurred in the ED (3.2%). Two of these patients had blood pressure cuffs placed on the same arm as the peripheral NE infusion. One patient had a suspected extravasation by the ICU team, but was never confirmed. No additional treatment was required for the extravasations beyond monitoring. Average APACHE II score was 21 ± 9.3 with an overall hospital mortality of 24%.
Conclusion: Administration of peripheral NE results in a low rate of extravasation when administered according to the VCU ED protocol.