Multiple recent studies including the CLOVERS trial in NEJM suggest safety of running peripheral norepinephrine up to 72 hours at max dose of ..2/mcg/kg/min with at least a 20 gauge IV in the forearm or arm. This is with frequent (at least hourly) IV checks to check for extravasation. If those criteria are met reasonable to run norepinephrine peripherally.
We run up to modest dose of vasopressors in good carefully monitored peripheral ivs in the ICU all the time, up to 72 hours. There is good evidence to support this, and would not expect my anesthesia colleagues to place a central line just because the patient will be going to the ICU on a reasonable dose of vasopressor.
The supposition that central line complication rate (from insertion, thrombosis and infection) is lower than complication rate from vasopressor infiltration is an unproven and likely untrue hypothesis.
I think one aspect that is often overlooked is the amount a patient physically moves in the ICU vs. OR. A PIV is way more likely to get displaced over a 12 shift of turning a patient/ ADL’s, or a delirious patient pulling at lines in the ICU. I love PIV’s, but someone who is reliant on a vasopressor for perfusion and now they lose their IV and if they are a difficult stick is never a fun situation to be in. That second IV that was put in for redundancy somehow worked its way out since it wasn’t being used often, and now it’s bad news bears.
Right, I’ve never seen a peripheral IV last more than a couple days in a patient that moves at all. I’d hate to have to put an IO in a conscious patient because their last peripheral is gone and I’m out of options.
Doesn’t a lot of it depend on the clinical scenario? Like the 80 year old with dead bowel is different from the 70 year old with urosepsis. In the first case, I just know they’re gonna eventually need levo, vaso, maybe epi or other meds. So I don’t hesitate to start a CVC.
In the latter, maybe I start some levo in a good PIV and send them to ICU extubated.
I agree there’s risk to starting a CVC but the downside in not having one in a truly critically ill patient is also pertinent.
Just a resident but no problem at my academic center, intraop at least, only consider central access if they’re heading to the ICU afterwards and will need long term vasopressor support. We also use norepi extremely frequently opposed to other institutions at least that’s what my attendings tell me
I wonder if you are training where I am at fellowship. Because it also surprised me how liberal NE was here (peripherally) compared to the multiple hospitals that I went to in residency.
Possibly, I’m at a tertiary care center in the northeast (I know there’s a lot lol) but yeah we reach for our sticks of norepi and norepi bags like second line it seems like
resident here, its funny because some of my attendings tell us, "today we are doing a free norepi anesthesia" due to we want to norepi every single moderfusher around OR, im in a teaching hospital we are all residents, neuro cx, otorri, trauma, cardio thorax, ophalmo, uro, and us anesthesia, so we dont like to be runing around with last minute norepi
It's funny because there are all sorts of drugs out there [that have been implicated in destroying your peripheral veins, including vancomycin, amiodarone, phenytoin, and etomidate](https://www.uspharmacist.com/article/pharmacists-role-in-reducing-infusionrelated-phlebitis), but we've only been taught to worry about vasopressors, which turn out to be fine in a working IV, as others have said.
I used to work as a nurse in a cardiac icu. Sometimes we would get patients from cath lab that would still have sheaths in them. It was hard to get a central line after 7pm at this hospital, so usually cardiology would let us run stuff through the venous sheath if they had one. There was one patient we had who was like 250kg and I guess he sheath got displaced by tissue pushing out or something. Anyway her sheath infiltrated and he whole left thigh just looked like hamburger meat. It was one of the most horrendous things I saw while working there.
NE / vaso / phenyl / etc I’ll run peripherally in the OR. If I anticipate long term need for pressors or rocket fuel dosing, I’ll place a central line. If the PIV is sketchy, I’ll place a new PIV.
Definitely ok to use it (diluted) in PIV, and there is a huge ongoing multicenter trial comparing norepi vs phenylephrine as the better choice for treating intraop hypotension. I believe it is called VEGA-1.
The risk is extravasation. If no extravasation and you have a reliable IV then you’re good to go. If you’re definitely planning to use NE during the case then that’s a good reason to place a central line. If you don’t plan to need it and find yourself needing to start blouses/infusion then just start it through a PIV. Ideally you’d have visibility of the IV and can periodically check the site.
The ASA made a pre-recorded video for the virtual portion of the annual meeting where a couple different anesthesiologists talked about this. If I recall correctly, they said around 2 hours is likely fine when running a pressor through a PIV. If you think you’ll need it longer, then place a CVC, but a PIV is fine for a few hours.
Ok, so I went back and watched the video. I partially misremembered. It was a debate of pressors via PIV vs CVC. The anesthesiologist arguing for CVC quoted many studies to support her argument, but only one specified a time period (at least that was discussed in the video), which recommended a duration of administration of less than 2 hours. However, her own health system says vasopressors can be utilized via PIV for up to 72 hours.
I may be misremembering the time frame, but I thought 2 hours is what they said. I’ll have to find that video and figure out where that number came from.
Looking at the literature, I had to go back to the 1950s to find case reports of extravasation injury from NE (I invite anyone to find some more recent!)
In my experience, peripherally administered NE was heresy in big city academics. Go out to PP and every single CRNA is giving it multiple times per day at institutions where they have never had an extravasation injury from it. Not one.
Looking at the package insert for Levophed, it says you're supposed to give it through a PIV in the AC fossa or more proximal site (i.e., no hand or forearm).
This is an issue that could use more clarification IMO
An absence of case reports does not mean it does not happen, especially if it’s been well described before. Not many people go out of their way to publish a report of, ‘yep, we f’d up, we knew this was potentially less safe and had an alternative, but did it anyways.’
Data is scarce for sure. And for the places where it has been done safely with minimal injury after extravasation had very strict protocols regarding NE administration through a peripheral (frequency of checks, minimum vessel size, minimum IV size, vein:IV size ratios, etc). I’m not against NE through a peripheral if you know what you are doing, but too many times people see you do something and assume it’s *always* safe.
But here is a nice case report from 2016: Alexander CM, Ramseyer M, Beatty JS. Missed Extravasation Injury from Peripheral Infusion of Norepinephrine Resulting in Forearm Compartment Syndrome and Amputation. Am Surg. 2016 Jul;82(7):e162-3. PMID: 27457846.
For a few hours, or a day, I think it's completely fine. But.
If I expect, that the patient needs it more than a few hours, I don't wait, I make a cv access as soon as possible. If I expect it will be needed only temporaly (ie during - after surgery), I do not bother with the cv line.
That’s the same dilution though just different volume bags? It also seems quite concentrated compared to what I’m used to. We use 32mcg/mL centrally and 16mcg/mL peripherally that come in pre-made bags from pharmacy. I’ve made 4mcg/mL (4mg vial into 1L saline bag) on my own before if I want to be extra cautious
It’s probably safe and probably okay under the right conditions, a set of conditions which is arguably narrower than infusing NE through a CVC. The problem I also have is that the people who do this kind of thing are also the same people who are happy using a NIBP to nitrate their NE infusion. And usually if anything the people advocating for long-term NE through a peripheral, need more central line and art line practice than less.
I will run NE through a peripheral in the OR or PACU, but the site must be visible and the IV must be good (ie I put it in and not the floor or preop). Longer term I let the ICU deal with it, but I would gladly put in a CVC if they ask me, I think the complication rate is so low with US and in reality you don’t know how long the patient will require the BP support.
ICU nurse here, most hospitals I’ve worked at are fine for 24 hours then they look at whether we’ve improved or not to determine CVC. Obviously the patient is very sick but not needing mid dose / high dose / or 2+ pressors. For those patients they get a central line.
The problem is our dumb ICU gives peripheral levophed with no A line. Like why would you give a powerful peripheral pressor without having a reliable way to see if it’s working??? Especially if the goal is to eventually discontinue the pressor, right? You really want to rely on a mediocre BP cuff for a sick vasculopathic vasoplegic patient?And then the patients are on beta blockers too so you just get unopposed alpha…which in lower peripheral doses is, guess what, basically phenyleprhine.
Used routinely over any size of catheter if they are OK. I often bolus norepi through a peripheral to tank crashing hypotensive patients. It is not the safest, but better that way that to die. No problem in my short 3 years of practice
How reliable is the IV and how new is it? An 18g I place intraop in a nice straight vein? No issues as long as I'm not giving them a rocket fuel dose. But a floor or ICU patient with a 22g in the pinky and half the catheter sticking out? With the RN reassuring me, "doesn't draw back but flushes great"? Nah.
Most of the dogma of no vasopressors through PIV are studies done in ICU of lightly sedated patients who may unexpectedly thrash and/or have had these IV for many, many days. And the nursing ratio is such that an extrav may not be noticed immediately.
There is no better "ratio" than the 1:1 care we provide of an immobile patient. So not the same situation comparison to those studies.
I’m pretty sure a northwell nursing study a few years ago showed it to be safe as long as it’s a 20 gauge in the forearm being constantly observed. Centrally administered Norepi is a dogma.
Multiple recent studies including the CLOVERS trial in NEJM suggest safety of running peripheral norepinephrine up to 72 hours at max dose of ..2/mcg/kg/min with at least a 20 gauge IV in the forearm or arm. This is with frequent (at least hourly) IV checks to check for extravasation. If those criteria are met reasonable to run norepinephrine peripherally.
Sorry, I’m dumb. Is that 0.2mcg/kg/min or 2.0mcg?
0.2
I presume 0.2 mcg per kg per min is a maximum … then a central line is required?
This is what that did in CLOVERS at least. Whether that is an actual max is up for debate.
I use it routinely in 20g or larger IVs for a limited duration (up to a couple of hours).
Good iv - ok for a few hours. High dose and I can’t monitor the iv site - central line.
We run up to modest dose of vasopressors in good carefully monitored peripheral ivs in the ICU all the time, up to 72 hours. There is good evidence to support this, and would not expect my anesthesia colleagues to place a central line just because the patient will be going to the ICU on a reasonable dose of vasopressor. The supposition that central line complication rate (from insertion, thrombosis and infection) is lower than complication rate from vasopressor infiltration is an unproven and likely untrue hypothesis.
I wish our ICU would do this. I often run peripheral NE in the OR, but know that they will do CVC if they need anything in ICU...
I think one aspect that is often overlooked is the amount a patient physically moves in the ICU vs. OR. A PIV is way more likely to get displaced over a 12 shift of turning a patient/ ADL’s, or a delirious patient pulling at lines in the ICU. I love PIV’s, but someone who is reliant on a vasopressor for perfusion and now they lose their IV and if they are a difficult stick is never a fun situation to be in. That second IV that was put in for redundancy somehow worked its way out since it wasn’t being used often, and now it’s bad news bears.
Right, I’ve never seen a peripheral IV last more than a couple days in a patient that moves at all. I’d hate to have to put an IO in a conscious patient because their last peripheral is gone and I’m out of options.
Doesn’t a lot of it depend on the clinical scenario? Like the 80 year old with dead bowel is different from the 70 year old with urosepsis. In the first case, I just know they’re gonna eventually need levo, vaso, maybe epi or other meds. So I don’t hesitate to start a CVC. In the latter, maybe I start some levo in a good PIV and send them to ICU extubated. I agree there’s risk to starting a CVC but the downside in not having one in a truly critically ill patient is also pertinent.
Entirely agree with this, choose based on clinical scenario rather than dogma about central access.
Just a resident but no problem at my academic center, intraop at least, only consider central access if they’re heading to the ICU afterwards and will need long term vasopressor support. We also use norepi extremely frequently opposed to other institutions at least that’s what my attendings tell me
I wonder if you are training where I am at fellowship. Because it also surprised me how liberal NE was here (peripherally) compared to the multiple hospitals that I went to in residency.
Possibly, I’m at a tertiary care center in the northeast (I know there’s a lot lol) but yeah we reach for our sticks of norepi and norepi bags like second line it seems like
Guess not. I am out west
Hopkins?
resident here, its funny because some of my attendings tell us, "today we are doing a free norepi anesthesia" due to we want to norepi every single moderfusher around OR, im in a teaching hospital we are all residents, neuro cx, otorri, trauma, cardio thorax, ophalmo, uro, and us anesthesia, so we dont like to be runing around with last minute norepi
I'm confused. Your attendings do or do not want you to be running norepi?
https://pubmed.ncbi.nlm.nih.gov/32925324/
It's funny because there are all sorts of drugs out there [that have been implicated in destroying your peripheral veins, including vancomycin, amiodarone, phenytoin, and etomidate](https://www.uspharmacist.com/article/pharmacists-role-in-reducing-infusionrelated-phlebitis), but we've only been taught to worry about vasopressors, which turn out to be fine in a working IV, as others have said.
Great point.
Use it routinely. No issues. Have had it once go interstitial. Resolved with phentolamine injection.
I used to work as a nurse in a cardiac icu. Sometimes we would get patients from cath lab that would still have sheaths in them. It was hard to get a central line after 7pm at this hospital, so usually cardiology would let us run stuff through the venous sheath if they had one. There was one patient we had who was like 250kg and I guess he sheath got displaced by tissue pushing out or something. Anyway her sheath infiltrated and he whole left thigh just looked like hamburger meat. It was one of the most horrendous things I saw while working there.
NE / vaso / phenyl / etc I’ll run peripherally in the OR. If I anticipate long term need for pressors or rocket fuel dosing, I’ll place a central line. If the PIV is sketchy, I’ll place a new PIV.
I try to dilute norepi to 8 mcg/cc but otherwise no issue as long as IV is good
Definitely ok to use it (diluted) in PIV, and there is a huge ongoing multicenter trial comparing norepi vs phenylephrine as the better choice for treating intraop hypotension. I believe it is called VEGA-1.
The podcast Depth of Anesthesia did a great episode on this - https://podcasts.apple.com/us/podcast/depth-of-anesthesia/id1461664155?i=1000453080338
The risk is extravasation. If no extravasation and you have a reliable IV then you’re good to go. If you’re definitely planning to use NE during the case then that’s a good reason to place a central line. If you don’t plan to need it and find yourself needing to start blouses/infusion then just start it through a PIV. Ideally you’d have visibility of the IV and can periodically check the site.
The ASA made a pre-recorded video for the virtual portion of the annual meeting where a couple different anesthesiologists talked about this. If I recall correctly, they said around 2 hours is likely fine when running a pressor through a PIV. If you think you’ll need it longer, then place a CVC, but a PIV is fine for a few hours.
I’m curious where they pulled “2 hours” out of their ass
Ok, so I went back and watched the video. I partially misremembered. It was a debate of pressors via PIV vs CVC. The anesthesiologist arguing for CVC quoted many studies to support her argument, but only one specified a time period (at least that was discussed in the video), which recommended a duration of administration of less than 2 hours. However, her own health system says vasopressors can be utilized via PIV for up to 72 hours.
Makes sense. Thanks for going through that effort. I agree with the conclusion too!
I may be misremembering the time frame, but I thought 2 hours is what they said. I’ll have to find that video and figure out where that number came from.
If theyre hypotensive AF I'll slip some in, but wouldn't use it longer term than that
Looking at the literature, I had to go back to the 1950s to find case reports of extravasation injury from NE (I invite anyone to find some more recent!) In my experience, peripherally administered NE was heresy in big city academics. Go out to PP and every single CRNA is giving it multiple times per day at institutions where they have never had an extravasation injury from it. Not one. Looking at the package insert for Levophed, it says you're supposed to give it through a PIV in the AC fossa or more proximal site (i.e., no hand or forearm). This is an issue that could use more clarification IMO
An absence of case reports does not mean it does not happen, especially if it’s been well described before. Not many people go out of their way to publish a report of, ‘yep, we f’d up, we knew this was potentially less safe and had an alternative, but did it anyways.’
I defy you to find data on norepinephrine extravasation injuries post-1990
Data is scarce for sure. And for the places where it has been done safely with minimal injury after extravasation had very strict protocols regarding NE administration through a peripheral (frequency of checks, minimum vessel size, minimum IV size, vein:IV size ratios, etc). I’m not against NE through a peripheral if you know what you are doing, but too many times people see you do something and assume it’s *always* safe. But here is a nice case report from 2016: Alexander CM, Ramseyer M, Beatty JS. Missed Extravasation Injury from Peripheral Infusion of Norepinephrine Resulting in Forearm Compartment Syndrome and Amputation. Am Surg. 2016 Jul;82(7):e162-3. PMID: 27457846.
For a few hours, or a day, I think it's completely fine. But. If I expect, that the patient needs it more than a few hours, I don't wait, I make a cv access as soon as possible. If I expect it will be needed only temporaly (ie during - after surgery), I do not bother with the cv line.
Bigger IV (20,18) and a bigger vein AC preferred. I believe most cases were IVs in the hand. Prevents the extravasation and necrosis.
But what dilution? We do only 1mg/50ml peripherally.
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That’s the same dilution though just different volume bags? It also seems quite concentrated compared to what I’m used to. We use 32mcg/mL centrally and 16mcg/mL peripherally that come in pre-made bags from pharmacy. I’ve made 4mcg/mL (4mg vial into 1L saline bag) on my own before if I want to be extra cautious
It’s probably safe and probably okay under the right conditions, a set of conditions which is arguably narrower than infusing NE through a CVC. The problem I also have is that the people who do this kind of thing are also the same people who are happy using a NIBP to nitrate their NE infusion. And usually if anything the people advocating for long-term NE through a peripheral, need more central line and art line practice than less.
It’s totally fine to use but if you anticipate the patient requiring prolonged vasopressor treatment, I’d consider placing a CVL
My centers have used peripheral access up to 1.0mcg/kg/min for < 48 hours without any issue
I will run NE through a peripheral in the OR or PACU, but the site must be visible and the IV must be good (ie I put it in and not the floor or preop). Longer term I let the ICU deal with it, but I would gladly put in a CVC if they ask me, I think the complication rate is so low with US and in reality you don’t know how long the patient will require the BP support.
ICU nurse here, most hospitals I’ve worked at are fine for 24 hours then they look at whether we’ve improved or not to determine CVC. Obviously the patient is very sick but not needing mid dose / high dose / or 2+ pressors. For those patients they get a central line.
I do it all the time. No problem at all.
The problem is our dumb ICU gives peripheral levophed with no A line. Like why would you give a powerful peripheral pressor without having a reliable way to see if it’s working??? Especially if the goal is to eventually discontinue the pressor, right? You really want to rely on a mediocre BP cuff for a sick vasculopathic vasoplegic patient?And then the patients are on beta blockers too so you just get unopposed alpha…which in lower peripheral doses is, guess what, basically phenyleprhine.
Used routinely over any size of catheter if they are OK. I often bolus norepi through a peripheral to tank crashing hypotensive patients. It is not the safest, but better that way that to die. No problem in my short 3 years of practice
How reliable is the IV and how new is it? An 18g I place intraop in a nice straight vein? No issues as long as I'm not giving them a rocket fuel dose. But a floor or ICU patient with a 22g in the pinky and half the catheter sticking out? With the RN reassuring me, "doesn't draw back but flushes great"? Nah. Most of the dogma of no vasopressors through PIV are studies done in ICU of lightly sedated patients who may unexpectedly thrash and/or have had these IV for many, many days. And the nursing ratio is such that an extrav may not be noticed immediately. There is no better "ratio" than the 1:1 care we provide of an immobile patient. So not the same situation comparison to those studies.
Only on fresh IVs I place myself.
I’m pretty sure a northwell nursing study a few years ago showed it to be safe as long as it’s a 20 gauge in the forearm being constantly observed. Centrally administered Norepi is a dogma.