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Management of Adults with COVID-19
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Ryan Hakimi, DO, MS, FNCS, NVS; Andrew C. Fritschle, PharmD, BCPS, BCCCP; Margaret D. Scheffler, MD, FAAP; Russel J. Roberts, PharmD, BCCCP, FCCM
Hemodynamic emergencies are common in the critical care arena. Once fluid resuscitation fails to meet targeted perfusion goals, vasopressor agents are warranted. Although it is ideal for patients to have central venous access for administration of vasopressors, the opportunity to gain this access before administration may not be feasible. At these times, clinicians may be forced to initiate vasopressor agents through peripheral intravenous (PIV) access to stabilize the patient before obtaining central venous access.
Historically, the use of central and arterial lines has been variable across unit types and institutions.1 Central venous catheters (CVCs) are associated with significant morbidity leading to complications in approximately 15% of patients.2 As such, current practice is to assess on a daily basis whether such lines are needed in order to minimize patient line days and associated risk.
The heightened awareness to reduce central line days— and associated complications—coupled with increasing PIV vasopressor administration experience in emergencies, has led to a growing body of literature and increased clinician comfort with PIV vasopressor administration.3,4 Previous concerns about extravasation leading to tissue necrosis may have been overestimated; the most recent studies demonstrate an extravasation risk of 2%-5%, with no patients requiring antidote administration or surgical intervention.3 Additionally, a recent systematic review suggested that, when PIV vasopressors are administered in the antecubital fossa for less than 4 hours, tissue extravasation is minimal.5
Most of the literature concerns PIV administration of phenylephrine. One large retrospective case series of 277 patients documented a mean maximum rate of phenylephrine infusion at 79 μg/min for an average of 19 hours, including 17% who received the infusion for up to 48 hours. Results of this study showed a 3% rate of IV infiltration without further consequences. Antecubital fossa PIV placement had the lowest risk of infiltration (0 events; n = 70).3
There is a modest amount of support in the literature for norepinephrine infusion via PIV administration. The largest case series describes 146 patients who received norepinephrine at an average infusion rate of 0.08 µg/ kg/min for a median duration of 7.5 hours, including 16 µg/mL, 32 µg/mL, and 64 µg/mL concentrations. Extravasation occurred in 3% of patients. None of them required surgical intervention.6
Critically ill children present unique challenges in these scenarios, including the technical difficulty of establishing central access in a timely fashion. Children are more likely than adults to present with peripheral vasoconstriction in the setting of septic shock, which can complicate attempts to secure central access.7 Thus, since 2012, it has been recommended to prioritize initiating vasoactive medications over waiting for central access.7 Recently, a single-institution retrospective study examined the rate of IV infiltration and harm from peripheral vasoactive infusions. This study of 102 patients, 63 (62%) of whom met criteria for septic shock, documented only 2 episodes of IV infiltration (2%), neither of which required any intervention.
A current review of the literature suggests that use of PIV access for administration of vasoactive mediations does not come without risk. However, misconceptions may exist related to the true rates of complications associated with PIV administration. If CVC access cannot be safely and quickly established during hemodynamic emergencies, PIV access is an appropriate temporary alternative. It is critical that, if PIV access is used for vasopressor administration, infusion durations should be minimized while balancing the need for CVC to minimize overall patient risk. Further observational data is needed to optimize medical decision-making and patient care.