A systematic review of extravasation and local tissue injury from administration of vasopressors through peripheral intravenous catheters and central venous catheters☆,☆☆
Introduction
Vasopressor medications are commonly administered in the emergency department and intensive care unit to treat hemodynamic instability in critically ill patients. Administration of vasopressors via catheters located in large central veins has become the preferred route due to concerns about adverse events resulting from peripheral intravenous (IV) use [1], [2]—especially local tissue ischemia secondary to the vasoconstrictive properties possessed by this class of medications [2].
Despite these concerns, using a peripheral IV to administer vasopressor may allow the medication to reach the patient sooner and reduce the time required to achieve hemodynamic stability and its concomitant clinical benefits. Although peripheral IV access is readily obtained in most patients, peripheral vasopressor administration is often avoided to minimize the risk of potential local tissue ischemia.
In some critically ill patients, the requirement for a central venous catheter (CVC) may delay administration of vasopressors while the catheter is placed (usually by a physician). This delay may have unintended negative consequences because patients must remain in a hemodynamically unstable condition while the CVC is inserted. In addition, CVC insertion during emergency circumstances may increase the risk of adverse events compared with CVC insertion for an elective procedure [3].
The evidence cited for avoiding peripheral administration of vasopressors is a sparse collection of case studies and expert opinion [4]. We sought to describe the literature for the current practice of avoiding peripheral administration of vasopressors due to concerns of local tissue ischemia. We performed a systematic review to describe published reports on local tissue injury or extravasation during the administration of vasopressor medications using a peripheral IV or a CVC, and the type of vasopressor medication infused, the site of administration, and/or the duration of infusion in these events.
Section snippets
Study design and database search
A systematic search was performed on January 17, 2014, using Medline, Embase, and the Cochrane Library databases. A review protocol was not registered or published. The search strategy was formulated with the aid of an experienced research librarian. Although no date restrictions were placed on our search, the dates of coverage at the time of the search were 1946 to 2014 for Medline, 1947 to 2014 for Embase, and 1992 to 2014 for the Cochrane Library. To minimize publication bias, we also did
Characteristics of study subjects
Our search identified a total of 86 371 references, of which 85 [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67], [68], [69], [70], [71], [72], [73], [74], [75], [76], [77],
Studies on peripheral administration of vasopressors
Of the 325 separate events of local tissue injury or vasopressor extravasation associated with administration of vasopressors, 318 events [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [19], [20], [21], [22], [23], [24], [25], [26], [27], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [68], [69],
Limitations
As with any review, our study is limited by reporting bias. Although we have collected published data regarding complications resulting from peripheral and central vasopressor infusion, it is likely some relevant events were not published, which weakens the conclusions of this review. As we searched only for events where complications resulted from administration of vasopressor, we cannot make conclusions comparing the frequency of these complications with instances where no complication
Discussion
Administration of vasopressors is a paramount management strategy in hemodynamically unstable patients [90]. Currently, administration of vasopressors via peripheral IVs is considered by some to be unsafe and is often discouraged, mainly due to concern of local tissue injury [2]. For this reason, administration of vasopressors via CVCs is often advocated [1], [2]. In our systematic review, we have found only observational reports of complications attributable to vasopressor administration via
Conclusions
Vasopressor medications are strong vasoconstrictors that can cause tissue hypoperfusion and injury. Published reports of local tissue injury and extravasation from vasopressor infusion via peripheral IVs are mainly case reports, and may not be representative of true practice. However, based on published reports, the occurrence of local tissue injury requires prolonged administration of vasopressors via peripheral IVs. In emergency situations, short-term administration (< 2 hours) of vasopressor
Acknowledgments
Research librarian Timothy Ruggles contributed to the design and conduct of the search. Mete Erdogan contributed to writing and formatting the final manuscript. Dr Green is supported by a Clinician Scientist Award from the Faculty of Medicine at Dalhousie University in Halifax, Nova Scotia, Canada.
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Financial support: Dr Green is supported by a Clinician Scientist Award from the Faculty of Medicine at Dalhousie University in Halifax, Nova Scotia, Canada.
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Conflicts of interest: The authors declare they have no competing interests.