Use of Inotropics by Peripheral Vascular Line in the First Hour of Treatment of Pediatric Septic Shock: Experience at an Emergency Department

Local Adverse Events Associated with Peripheral Vasoactive Infusion in Children: A Systematic Review with Meta-analysis

Prior meta-analysis suggested a low incidence of local adverse events after infusion of vasoactive agents via a peripheral venous catheter in children. However, the number of included patients was relatively low, and the vasoactive agents used were mostly dopamine. We performed an updated systematic review with meta-analysis using databases of MEDLINE (via PubMed) and Cochrane Central Register of Controlled Trials to explore the safety of infusing vasoactive agents, including epinephrine and norepinephrine, through peripheral venous catheters or intraosseous access in critically ill children. The primary outcome was the occurrence of local adverse events associated with peripheral vasoactive infusion, such as extravasation or infiltration. Twelve observational studies and 1 randomized controlled trial were finally included. The pooled incidence rates of local adverse events associated with infusion of vasoactive agents through peripheral venous catheters or intraosseous access, peripheral venous catheters only, and intraosseous access only were 2.1% (95% confidence interval [CI]: 0.8%-3.9%), 2.3% (95% CI: 1.0%-4.0%), and 1.1% (95% CI: 0.0%-9.8%), respectively. Based on the findings of this meta-analysis, the incidence rate of local adverse events associated with peripheral vasoactive infusion appears to be low. Peripheral infusion of vasoactive agents, including epinephrine and norepinephrine, can be considered when necessary.

Safety and outcomes of short-term use of peripheral vasoactive infusions in critically ill paediatric population in the emergency department

Early restoration of oxygen delivery to end organs in paediatric patients experiencing shock states is critical to optimizing outcomes. However, obtaining central access in paediatric patients may be challenging in non-intensive care settings. There is limited literature on the use of peripheral vasoactive infusions in the initial resuscitation of paediatric patients in the emergency department. The aims of this study were to report the associated complications of peripheral vasoactive infusions and describe our local experience on its use. This was a single-centre, retrospective study on all paediatric patients who received peripheral vasoactive infusions at our paediatric emergency department from 2009 to 2016. 65 patients were included in this study. No patients had any local or regional complications. The mean patient age was 8.29 years old (± 5.99). The most frequent diagnosis was septic shock (45, 69.2%). Dopamine was the most used peripheral vasoactive agent (71.2%). The median time to central agents was 2 h (IQR 1-4). 16(24.2%) received multiple peripheral infusions. We reported no complications of peripheral vasoactive infusions. Its use could serve as a bridge till central access is obtained. Considerations on the use of multiple peripheral vasoactive infusions in the emergency department setting needs further research.

Peripheral Vasoactive Administration in Critically Ill Children With Shock: A Single-Center Retrospective Cohort Study

OBJECTIVES

Management of fluid refractory pediatric shock requires prompt administration of vasoactive agents. Although delivery of vasoactive therapy is generally provided via a central venous catheter, their placement can delay drug administration and is associated with complications. We characterize peripheral vasoactive administration in a cohort of critically ill children with shock, evaluate progression to central venous catheter placement, and describe complications associated with extravasation.

DESIGN

Retrospective cohort study.

SETTING

Single-center, quaternary PICU (January 2010 to December 2015).

PATIENTS

Children (31 d to 18 yr) who received epinephrine, norepinephrine, or dopamine.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We compared patients based on the initial site of vasoactive infusion: peripheral venous access (PVA) or central venous access (CVA) and, within the PVA group, compared patients based on subsequent placement of a central catheter for vasoactive infusion. We also characterized peripheral extravasations. We evaluated 756 patients: 231 (30.6%) PVA and 525 (69.4%) CVA patients. PVA patients were older, had lower illness severity, and more frequently had vasoactive therapy initiated at night compared with CVA patients. In PVA patients, 124 (53.7%) had a central catheter placed after a median of 140 minutes (interquartile range, 65-247 min) of peripheral treatment. Patients who avoided central catheter placement had lower illness severity. Of the 93 patients with septic shock, 44 (47.3%) did not have a central catheter placed. Extravasations occurred in four of 231 (1.7% [95% CI, 0.03-3.4]) PVA patients, exclusively in the hand. Three patients received pharmacologic intervention, and none had long-term disabilities.

CONCLUSIONS

In our experience, peripheral venous catheters can be used for vasoactive administration. In our series, the upper limit of the 95% CI for extravasation is approximately 1-in-30, meaning that this route may be an appropriate option while evaluating the need for central access, particularly in patients with low illness severity.