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A6854 - Implementation of an ICU Protocol for Peripheral Administration of Vasopressors
Author Block: N. Patel, R. Scatena, A. M. Ahasic; Pulmonary, Norwalk Hospital, Norwalk, CT, United States.
Introduction: Central venous access has conventionally been required for infusion of vasopressors in shock states. The risk of extravasation of vasopressors into tissues and stability of peripheral IVs have been of greatest concern. Recent reviews have attempted to examine safety outcomes from existing literature, but much of the published data is limited to case reports. There has also been interest in quality metrics such as decreasing catheter-related blood stream infections(CLABSIs) by decreased use of centrally placed catheters. We report on the experience of implementing an intensive care unit(ICU) protocol for vasopressor infusion through peripheral veins.
Methods: We studied implementation of a rigorous protocol for peripheral vasopressor use in a 16-bed ICU in a community-based teaching hospital, written and approved collaboratively with nursing, physician, and pharmacy input. The protocol included requirements for IV size and location, confirmation of intraluminal IV placement by ultrasound, maximal concentration and dose of vasopressors allowed, and a rescue protocol for extravasation. We reviewed hospital records of all patients in whom the protocol was implemented since its initiation for deviation from protocol or adverse events. Data: Fourteen patients received peripheral vasopressors in the first three months after implementation. Nine(64%) were male and the mean age was 70(range 43-94). Mean duration of vasopressor infusion was 11.3 hours(range 3 to 47 hours). There were 3 peripheral IVs present on average during the period of vasopressor infusion. Eight patients(57%) required escalation to a centrally placed venous catheter within 14 days for ongoing central or stable access needs. Two patients died, unrelated to peripheral vasopressor use. Only 1 patient had extravasation of vasopressors with no local complications after per-protocol use of phentolamine at the site. The most common vasoactive agent infused was norepinephrine. While the elements of the protocol were generally followed appropriately we found that documentation of ultrasound verification of intraluminal placement of peripheral IVs was lacking in most cases
Conclusions: We demonstrate implementation of a protocol for use of peripherally infused vasopressors with minimal adverse events, and successful use of phentolamine for extravasation as part of the protocol. We also describe success of developing such a protocol in a multidisciplinary way involving multiple key stakeholders. Further education of staff may help improve protocol adherence in documenting ultrasound verification of IV placement. Further research is needed over a longer time-period for more robust examination of adverse events, changes in rates of central venous catheter placement, and overall patient outcomes.