References:
General References:
- Lachkine, J. et al. Development and Validation of a Multivariable Model Predicting the Required Catheter Dwell Time Among Mechanically Ventilated Critically Ill Patients in Three Randomized Trails. Annal of Intensive Care 2023.
- The study developed and validated the CVC-IN score to predict the required catheter dwell time for critically ill, mechanically ventilated patients, helping to identify those at a higher risk of intravascular complications based on factors such as immunosuppression, high creatinine levels, vasopressor use, obesity, and age. Though the score showed modest discrimination ability, favoring subclavian site insertion may reduce the complication risk, particularly in patients with a higher CVC-IN score. However, insertion of a subclavian device must be performed by a skill operator to avoid insertion-related complications (e.g., pneumothorax)
- Miller, D. et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections: Recommendations Relevant to Interventional Radiology for Venous Catheter Placement and Maintenance Journal of Vascular and Interventional Radiology 2012.
- In the U.S., CRBSIs significantly impact ICU costs and hospital stays, prompting updates in CDC guidelines to improve prevention, with key recommendations including maximum sterile barrier precautions, the use of chlorhexidine-alcohol for skin antisepsis, and targeted use of impregnated catheters. Despite advancements laid out in the 2011 revised guidelines, which emphasize education, proper catheter maintenance, and evidence-based practices, implementation remains suboptimal, as many hospitals continue to omit crucial preventative measures such as maximum sterile precautions and avoid unnecessary routine catheter changes.
Peripheral Use of Vasopressors
- Cardenas-Garcia, J. et al. Safety of Peripheral Intravenous Administration of Vasoactive Medication. J of Hosp Med 2015.
- Administration of norepinephrine, dopamine, or phenylephrine by peripheral intravenous access was feasible and safe in this single-center medical intensive care unit. This study was the first to suggest that use of vasoactive medication may not need to be an automatic indication for central venous access in environments where the peripheral IV can be closely monitored and there are protocols in place that allow teams to respond to extravasation quickly to prevent tissue injury.
- Munroe, E. et al. Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study. CHEST 2023.
- Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, the findings of wide practice variation that was not explained by patient case mix and lower use of first-line norepinephrine with peripheral administration suggest that additional standardization may be needed.
- Associated Podcast Episode: CHEST Journal Podcast - April 2024
- Yerke, J. R. et al. Peripheral Administration of Norepinephrine: A Prospective Observational Study. CHEST 2024.
- A prospective observational cohort study assessing the use of a protocol for peripheral norepinephrine administration in medical ICU patients. The primary outcome was number of days of CVC use avoided and secondary outcome was incidence of extravasation events. The study suggests that implementing a protocol for peripheral norepinephrine administration can safely avoid 1 CVC day in the average patient and result in few extravasation events causing minimal or no tissue injury. Protocols for close peripheral IV monitoring is key to catch extravasations early and prevent tissue injury.
- Munroe, E. A Case for the Evidence-Based Use of Peripheral Vasopressors. CHEST 2024.
- Recent studies, including one by Yerke et al. in an ICU setting, demonstrate that peripheral vasopressor administration, specifically norepinephrine, can effectively reduce the need for central venous catheters (CVCs) while maintaining a low rate of manageable extravasation events. Despite potential protocol variability and challenges in developing standardized guidelines, the findings support the safe integration of peripheral vasopressors into clinical practice, highlighting the importance of close monitoring and rapid response mechanisms to minimize complications.