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Han P, Zhou Y. Safety and efficacy of peripheral metaraminol infusion in patients with neurological conditions: a single-center retrospective observational study. Front Neurol 2024; 15:1398827. [PMID: 38887388 PMCID: PMC11180898 DOI: 10.3389/fneur.2024.1398827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 05/16/2024] [Indexed: 06/20/2024] Open
Abstract
Introduction Metaraminol is a sympathomimetic amine vasopressor that can be administrated through a peripheral venous access. However, limited evidence restricts its application in critically ill patients. This study aimed to investigate the safety and efficacy of peripheral metaraminol infusion in patients with neurological conditions. Methods Patients who received peripheral metaraminol infusion between May 2019 and April 2022 were recruited. Data on baseline characteristics, clinical parameters, and infusion-related complications were retrospectively collected and analyzed. Results 273 patients who received metaraminol were enrolled. Of these, 35 (12.8%) patients required central venous catheter insertion due to inability in achieving hemodynamic stability following peripheral metaraminol monotherapy. In 29,574.2 hours of vasopressor infusion, metaraminol infusion resulted achievement of the target blood pressure 73.4% of the time. Meanwhile, adverse events occurred in 5 patients and resolved after local tissue treatment. Discussion Metaraminol could provide hemodynamic support and avoid complications associated with a central venous catheter and delay in vasopressor administration. Through careful and close monitoring, peripheral metaraminol infusion is safe and feasible for patients with neurological conditions. Future large-scale, prospective, multicenter studies are needed to evaluate the safety and efficacy of metaraminol infusion through a peripheral intravenous catheter.
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Affiliation(s)
- Pan Han
- General ICU, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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2
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Christensen J, Andersson E, Sjöberg F, Hellgren E, Harbut P, Harbut J, Sjövall F, von Bruhn Gufler C, Mårtensson J, Rubenson Wahlin R, Joelsson-Alm E, Cronhjort M. Adverse Events of Peripherally Administered Norepinephrine During Surgery: A Prospective Multicenter Study. Anesth Analg 2024; 138:1242-1248. [PMID: 38180886 DOI: 10.1213/ane.0000000000006806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
BACKGROUND Perioperative treatment of hypotension by intravenous administration of norepinephrine in a peripheral vein can lead to adverse events, for example, tissue necrosis. However, the incidence and severity of adverse events during perioperative administration are unknown. METHODS This was a prospective observational study conducted at 3 Swedish hospitals from 2019 to 2022. A total of 1004 patients undergoing surgery, who met the criteria for perioperative peripheral norepinephrine administration, were included. The infusion site was inspected regularly. If swelling or paleness of skin was detected, the infusion site was changed to a different peripheral line. Systolic blood pressure and pulse frequency were monitored during the infusion time and defined as adverse events at >220 mm Hg and <40 beats•min -1 . In case of adverse events, patients were observed for up to 48 hours. The primary outcome was prevalence of extravasation, defined as swelling around the infusion site. Secondary outcomes were all types of adverse events and associations between predefined clinical variables and risk of adverse events. RESULTS We observed 2.3% (95% confidence interval [CI], 1.4%-3.2%) extravasation of infusion and 0.9% (95% CI, 0.4%-1.7%) bradycardia. No cases of tissue necrosis or severe hypertension were detected. All adverse events had dissipated spontaneously within 48 hours. Proximal catheter placement was associated with more adverse events. CONCLUSIONS Extravasation of peripherally administrated norepinephrine in the perioperative period occurred at similar rates as in previous studies in critically ill patients. In our setting, where we regularly inspected the infusion site and shifted site in case of swelling or paleness of skin, we observed no case of severe adverse events. Given that severe adverse events were absent, the potential benefit of this preventive approach requires confirmation in a larger population.
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Affiliation(s)
- Jens Christensen
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Elisabeth Andersson
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Fredric Sjöberg
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Elisabeth Hellgren
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Piotr Harbut
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
| | - Joanna Harbut
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
| | - Fredrik Sjövall
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | | | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Section of Anaesthesia and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Eva Joelsson-Alm
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Maria Cronhjort
- From the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesia and Intensive Care, Danderyd Hospital, Stockholm, Sweden
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3
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Watts S, Apte Y, Holland T, Hatt A, Craswell A, Lin F, Tabah A, Ware R, Byrnes J, Anstey C, Keijzers G, Ramanan M. Randomised, controlled, feasibility trial comparing vasopressor infusion administered via peripheral cannula versus central venous catheter for critically ill adults: A study protocol. PLoS One 2024; 19:e0295347. [PMID: 38739611 PMCID: PMC11090297 DOI: 10.1371/journal.pone.0295347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/11/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND When clinicians need to administer a vasopressor infusion, they are faced with the choice of administration via either peripheral intravenous catheter (PIVC) or central venous catheter (CVC). Vasopressor infusions have traditionally been administered via central venous catheters (CVC) rather than Peripheral Intra Venous Catheters (PIVC), primarily due to concerns of extravasation and resultant tissue injury. This practice is not guided by contemporary randomised controlled trial (RCT) evidence. Observational data suggests safety of vasopressor infusion via PIVC. To address this evidence gap, we have designed the "Vasopressors Infused via Peripheral or Central Access" (VIPCA) RCT. METHODS The VIPCA trial is a single-centre, feasibility, parallel-group RCT. Eligible critically ill patients requiring a vasopressor infusion will be identified by emergency department (ED) or intensive care unit (ICU) staff and randomised to receive vasopressor infusion via either PIVC or CVC. Primary outcome is feasibility, a composite of recruitment rate, proportion of eligible patients randomised, protocol fidelity, retention and missing data. Primary clinical outcome is days alive and out of hospital up to day-30. Secondary outcomes will include safety and other clinical outcomes, and process and cost measures. Specific aspects of safety related to vasopressor infusions such as extravasation, leakage, device failure, tissue injury and infection will be assessed. DISCUSSION VIPCA is a feasibility RCT whose outcomes will inform the feasibility and design of a multicentre Phase-3 trial comparing routes of vasopressor delivery. The exploratory economic analysis will provide input data for the full health economic analysis which will accompany any future Phase-3 RCT.
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Affiliation(s)
| | - Yogesh Apte
- Caboolture Hospital, Caboolture, Australia
- James Mayne Academy of Critical Care, The University of Queensland, Brisbane, Australia
| | | | - April Hatt
- Caboolture Hospital, Caboolture, Australia
| | - Alison Craswell
- Caboolture Hospital, Caboolture, Australia
- School of Health, University of the Sunshine Coast, Sippy Downs, Australia
| | - Frances Lin
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Sunshine Coast Health Institute, School of Health, University of the Sunshine Coast, Sippy Downs, Australia
| | - Alexis Tabah
- James Mayne Academy of Critical Care, The University of Queensland, Brisbane, Australia
- Intensive Care Unit, Redcliffe Hospital, Brisbane, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Queensland Critical Care Research Network, Herston, Australia
| | - Robert Ware
- Menzies Health Institute Queensland and School of Medicine and Dentistry, Griffith University, Southport, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Southport, Australia
| | - Christopher Anstey
- Menzies Health Institute Queensland and School of Medicine and Dentistry, Griffith University, Southport, Australia
| | - Gerben Keijzers
- Menzies Health Institute Queensland and School of Medicine and Dentistry, Griffith University, Southport, Australia
- Department of Emergency Medicine, Gold Coast Hospital and Health Service, Southport, Australia
- Faculty of Health Sciences and Medicine Bond University, Robina, Australia
| | - Mahesh Ramanan
- Caboolture Hospital, Caboolture, Australia
- Queensland Critical Care Research Network, Herston, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Kensington, Australia
- Faculty of Health, Queensland of Technology, Brisbane, Australia
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4
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Mergoum AM, Rhone AR, Larson NJ, Dries DJ, Blondeau B, Rogers FB. A Guide to the Use of Vasopressors and Inotropes for Patients in Shock. J Intensive Care Med 2024:8850666241246230. [PMID: 38613381 DOI: 10.1177/08850666241246230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.
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Affiliation(s)
| | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
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5
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Samara E, Tzimas PG, El Tahan MR. How to "Endgame" Safe Peripheral Vasopressor Administration. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00241-6. [PMID: 38908929 DOI: 10.1053/j.jvca.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Evangelia Samara
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Petros G Tzimas
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Mohamed R El Tahan
- Cardiothoracic Anesthesia, Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; Cardiothoracic Anesthesia Unit, Department of Anesthesia, Surgical Intensive Care and Pain Medicine, College of Medicine, Mansoura University, Mansour, Egypt
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6
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Munroe ES, Heath ME, Eteer M, Gershengorn HB, Horowitz JK, Jones J, Kaatz S, Tamae Kakazu M, McLaughlin E, Flanders SA, Prescott HC. Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study. Chest 2024; 165:847-857. [PMID: 37898185 PMCID: PMC11214906 DOI: 10.1016/j.chest.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/09/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Vasopressors traditionally are administered via central access, but newer data suggest that peripheral administration may be safe and may avoid delays and complications associated with central line placement. RESEARCH QUESTION How commonly are vasopressors initiated through peripheral IV lines in routine practice? Is vasopressor initiation route associated with in-hospital mortality? STUDY DESIGN AND METHODS This retrospective cohort study included adults hospitalized with sepsis (November 2020-September 2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement. RESULTS Five hundred ninety-four patients received vasopressors within 6 h of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594 [67.3%]). Patients with peripheral vs central initiation were similar; BMI was the only patient factor associated independently with initiation route (adjusted OR [aOR] of peripheral initiation [per 1-kg/m2 increase], 0.98; 95% CI, 0.97-1.00; P = .015). The specific hospital showed a large impact on initiation route (median OR, 2.19; 95% CI, 1.31-3.07). Compared with central initiation, peripheral initiation was faster (median, 2.5 h vs 2.7 h from hospital arrival; P = .002), but was associated with less initial norepinephrine use (84.3% vs 96.8%; P = .001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%; aOR, 0.66; 95% CI, 0.39-1.12). No tissue injury from peripheral vasopressors was documented. Of patients with peripheral initiation, 135 of 400 patients (33.8%) never received a central line. INTERPRETATION 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.
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Affiliation(s)
- Elizabeth S Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI.
| | - Megan E Heath
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Mousab Eteer
- Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL; Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Jennifer K Horowitz
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Jessica Jones
- Department of Pharmacy, Corewell Health, Dearborn, MI
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Health, Detroit, MI
| | | | - Elizabeth McLaughlin
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
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7
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Darwish D, Karamchandani K. PRO: Vasopressors Can Be Administered Safely via a Peripheral Intravenous Catheter. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00105-8. [PMID: 38453557 DOI: 10.1053/j.jvca.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Dana Darwish
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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8
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Yerke JR, Mireles-Cabodevila E, Chen AY, Bass SN, Reddy AJ, Bauer SR, Kokoczka L, Dugar S, Moghekar A. Peripheral Administration of Norepinephrine: A Prospective Observational Study. Chest 2024; 165:348-355. [PMID: 37611862 PMCID: PMC10851275 DOI: 10.1016/j.chest.2023.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Historically, norepinephrine has been administered through a central venous catheter (CVC) because of concerns about the risk of ischemic tissue injury if extravasation from a peripheral IV catheter (PIVC) occurs. Recently, several reports have suggested that peripheral administration of norepinephrine may be safe. RESEARCH QUESTION Can a protocol for peripheral norepinephrine administration safely reduce the number of days a CVC is in use and frequency of CVC placement? STUDY DESIGN AND METHODS This was a prospective observational cohort study conducted in the medical ICU at a quaternary care academic medical center. A protocol for peripheral norepinephrine administration was developed and implemented in the medical ICU at the study site. The protocol was recommended for use in patients who met prespecified criteria, but was used at the treating clinician's discretion. All adult patients admitted to the medical ICU receiving norepinephrine through a PIVC from February 2019 through June 2021 were included. RESULTS The primary outcome was the number of days of CVC use that were avoided per patient, and the secondary safety outcomes included the incidence of extravasation events. Six hundred thirty-five patients received peripherally administered norepinephrine. The median number of CVC days avoided per patient was 1 (interquartile range, 0-2 days per patient). Of the 603 patients who received norepinephrine peripherally as the first norepinephrine exposure, 311 patients (51.6%) never required CVC insertion. Extravasation of norepinephrine occurred in 35 patients (75.8 events/1,000 d of PIVC infusion [95% CI, 52.8-105.4 events/1,000 d of PIVC infusion]). Most extravasations caused no or minimal tissue injury. No patient required surgical intervention. INTERPRETATION This study suggests that implementing a protocol for peripheral administration of norepinephrine safely can avoid 1 CVC day in the average patient, with 51.6% of patients not requiring CVC insertion. No patient experienced significant ischemic tissue injury with the protocol used. These data support performance of a randomized, prospective, multicenter study to characterize the net benefits of peripheral norepinephrine administration compared with norepinephrine administration through a CVC.
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Affiliation(s)
- Jason R Yerke
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH.
| | | | - Alyssa Y Chen
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | | | - Anita J Reddy
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH
| | | | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ajit Moghekar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
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9
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Koch F, Green M, Dietrich M, Moikow L, Ritz JP. [The "Big Five" of Invasiveness - the Usefulness of Drains, Probes and Catheters in Colorectal Surgery]. Zentralbl Chir 2023; 148:406-414. [PMID: 34666401 DOI: 10.1055/a-1533-2612] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The perioperative management of colorectal resections is often dominated by traditional procedures and a strong focus on safety. Evidence-based measures such as those established in Fast Track or ERAS programs, are rarely applied in a standardised manner. As part of elective colorectal surgery, many patients therefore continue to routinely receive central venous access, peridural catheters, urinary catheters, drains and/or gastric tubes ("Big Five" of invasiveness). This article presents the currently available evidence on these measures in colorectal surgery. In addition, results relating to the "Big Five" from the author's own centre are presented. This review shows that the "Big Five" of invasiveness are clinically unnecessary or supported by evidence. In addition, they often impair the patient's function.
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Affiliation(s)
- Franziska Koch
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Martina Green
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Melanie Dietrich
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Lutz Moikow
- Klinik für Anästhesiologie, HELIOS Kliniken Schwerin, Schwerin, Deutschland
| | - Jörg-Peter Ritz
- Klinik für Allgemein- und Viszeralchirurgie, HELIOS Kliniken Schwerin, Schwerin, Germany
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10
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García-Uribe J, Lopera-Jaramillo D, Gutiérrez-Vargas J, Arteaga-Noriega A, Bedoya OA. Adverse effects related with norepinephrine through short peripheral venous access: Scoping review. ENFERMERIA INTENSIVA 2023; 34:218-226. [PMID: 36935306 DOI: 10.1016/j.enfie.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 09/01/2022] [Indexed: 03/19/2023]
Abstract
Peripheral administration of norepinephrine is restricted due to the association of extravasation with tissue necrosis. METHOD Scoping review with the objective of describing the adverse effects related to the administration of norepinephrine through short peripheral venous access and the characteristics of drug administration in patients hospitalized in ICU, surgery, and emergency services. RESULTS 12 studies with heterogeneous characteristics by size and type of population were included. The proportion of complications associated with peripheral norepinephrine administration was less than 12% in observational studies and it was less than 2% in those that used doses less than 0.13μg/kg/min, and concentrations less than 22.3μg/mL. The main associated complication was extravasation and there were no cases of tissue necrosis at the venipuncture site, some extravasation cases were treated with phentolamine, terbutaline or topical nitroglycerin. The drug administration time ranged between 1 and 528hours with a weighted mean of 2.78h. CONCLUSION The main adverse effect was extravasation, no additional complications occurred, phentolamine and terbutaline seem to be useful, and its availability is a necessity. It is essential for the nursing staff to carry out a close assessment and comprehensive care in patients receiving norepinephrine by peripheral route.
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Affiliation(s)
- J García-Uribe
- Facultad de Ciencias de la Salud, Corporación Universitaria Remington, Medellín, Colombia.
| | - D Lopera-Jaramillo
- Facultad de Ciencias de la Salud, Corporación Universitaria Remington, Medellín, Colombia.
| | - J Gutiérrez-Vargas
- Grupo de Investigación Salud Familiar y Comunitaria, Facultad de Ciencias de la Salud, Corporación Universitaria Remington, Medellín, Colombia.
| | - A Arteaga-Noriega
- Grupo de Investigación Salud Familiar y Comunitaria, Facultad de Ciencias de la Salud, Corporación Universitaria Remington, Medellín, Colombia.
| | - O A Bedoya
- Grupo de Investigación Salud Familiar y Comunitaria, Facultad de Ciencias de la Salud, Corporación Universitaria Remington, Medellín, Colombia.
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11
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Asher E, Karameh H, Nassar H, Yosefy C, Marmor D, Perel N, Taha L, Tabi M, Braver O, Shuvy M, Wiener-Well Y, Glikson M, Bruoha S. Safety and Outcomes of Peripherally Administered Vasopressor Infusion in Patients Admitted with Shock to an Intensive Cardiac Care Unit-A Single-Center Prospective Study. J Clin Med 2023; 12:5734. [PMID: 37685801 PMCID: PMC10488618 DOI: 10.3390/jcm12175734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/23/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Vasopressors are frequently utilized for blood pressure stabilization in patients with cardiogenic shock (CS), although with a questionable benefit. Obtaining central venous access is time consuming and may be associated with serious complications. Hence, we thought to evaluate whether the administration of vasopressors through a peripheral venous catheter (PVC) is a safe and effective alternative for the management of patients with CS presenting to the intensive cardiovascular care unit (ICCU). METHODS A prospective single-center study was conducted to compare the safety and outcomes of vasopressors administered via a PVC vs. a central venous catheter (CVC) in patients presenting with CS over a 12-month period. RESULTS A total of 1100 patients were included; of them, 139 (12.6%) required a vasopressor treatment due to shock, with 108 (78%) treated via a PVC and 31 (22%) treated via a CVC according to the discretion of the treating physician. The duration of the vasopressor administration was shorter in the PVC group compared with the CVC group (2.5 days vs. 4.2 days, respectively, p < 0.05). Phlebitis and the extravasation of vasopressors occurred at similar rates in the PVC and CVC groups (5.7% vs. 3.3%, respectively, p = 0.33; 0.9% vs. 3.3%, respectively, p = 0.17). Nevertheless, the bleeding rate was higher in the CVC group compared with the PVC group (3% vs. 0%, p = 0.03). CONCLUSIONS The administration of vasopressor infusions via PVC for the management of patients with CS is feasible and safe in patients with cardiogenic shock. Further studies are needed to establish this method of treatment.
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Affiliation(s)
- Elad Asher
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Hani Karameh
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Hamed Nassar
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Chaim Yosefy
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
| | - David Marmor
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Nimrod Perel
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Louay Taha
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Meir Tabi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Omri Braver
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
| | - Mony Shuvy
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Yonit Wiener-Well
- Infectious Diseases Unit, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel;
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91121, Israel; (E.A.); (H.K.); (H.N.); (D.M.); (N.P.); (L.T.); (M.T.); (M.S.); (M.G.)
| | - Sharon Bruoha
- Department of Cardiology, Barzilai Medical Center, The Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel; (C.Y.); (O.B.)
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Powell SM, Faust AC, George S, Townsend R, Eubank D, Kim R. Effect of Peripherally Infused Norepinephrine on Reducing Central Venous Catheter Utilization. JOURNAL OF INFUSION NURSING 2023; 46:210-216. [PMID: 37406335 DOI: 10.1097/nan.0000000000000508] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The purpose of this retrospective study was to evaluate the impact of peripherally administered norepinephrine on avoiding central venous catheter insertion while maintaining safety of the infusion. An institutional guideline allows peripheral infusion of norepinephrine via dedicated, 16- to 20-gauge, mid-to-upper arm intravenous (IV) catheters for up to 24 hours. The primary outcome was the need for central venous access in patients initially started on peripherally infused norepinephrine. A total of 124 patients were evaluated (98 initially on peripherally infused norepinephrine vs 26 with central catheter only administration). Thirty-six (37%) of the 98 patients who were started on peripheral norepinephrine avoided the need for central catheter placement, which was associated with $8,900 in direct supply cost avoidance. Eighty (82%) of the 98 patients who started peripherally infused norepinephrine required the vasopressor for ≤12 hours. No extravasation or local complications were observed in any of the 124 patients, regardless of site of infusion. Administration of norepinephrine via a dedicated peripheral IV site appears safe and may lead to a reduction in the need for subsequent central venous access. To achieve timely resuscitation goals, as well as to minimize complications associated with central access, initial peripheral administration should be considered for all patients.
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Affiliation(s)
- Sara M Powell
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Andrew C Faust
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Stephy George
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Richard Townsend
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Darla Eubank
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
| | - Richard Kim
- Department of Pharmacy (Drs Powell, Faust, and George) and Infusion Support Team, Department of Nursing (Mr Townsend and Ms Eubank), Texas Health Presbyterian Hospital Dallas, Dallas, Texas; Sound Physician Group, Pulmonary/Critical Care Medicine, Dallas, Texas (Dr Kim)
- Sara M. Powell, PharmD, MS, is the current postgraduate year 2 Critical Care pharmacy resident at Texas Health Dallas, where she also completed her postgraduate year 1 Pharmacy Practice residency. She received her Master of Science degree in 2016 and Doctor of Pharmacy degree in 2021 from Texas Tech University Health Sciences Center in Lubbock, Texas. Dr Powell has research and practice interests in anticoagulant reversal, septic shock management, antimicrobial stewardship, and trauma. Andrew C. Faust, PharmD, BCPS, is the current medical intensive care unit clinical pharmacy specialist at Texas Health Dallas and has been in this role since 2011. He graduated pharmacy school from the University of Texas at Austin in 2009 and followed that with a postgraduate year 1 Pharmacy Practice residency at University Health in San Antonio, Texas, and a postgraduate year 2 Critical Care pharmacy residency at Methodist University Hospital in Memphis, Tennessee. Dr Faust has published multiple articles in the areas of critical care, anticoagulation, and infectious diseases and has interests in management of sepsis/shock, rationale antimicrobial use in critically ill patients, and sedation/analgesia management. Stephy George, PharmD, BCCCP, is the current emergency department (ED)/trauma clinical pharmacy specialist. She graduated from University of Houston College of Pharmacy in 2013 and completed her pharmacotherapy postgraduate year 1 at Methodist Hospital in San Antonio and Critical Care and postgraduate year 2 at North Texas VA/Texas Tech Health Science Center in Dallas before starting her career as a critical care pharmacy specialist in 2016. Her clinical areas of interest are multimodal pain management, ICU antimicrobial stewardship, and management of agitation in the ED. Richard Townsend, RN, has worked as a vascular access nurse at Texas Health Dallas since March of 2020. He graduated from nursing school in 2006 and has prior experience in intensive care nursing, emergency nursing as a medicine and trauma nurse, and in the cardiac catheterization laboratory. Darla Eubank, RN, received her Bachelor of Science in Nursing from Abilene Christian University in 1996. After graduation, she worked as a telemetry nurse, cardiac catheterization laboratory nurse, and progressive cardiac care unit charge nurse. She has been an infusion support nurse at Texas Health Dallas since 2003 and now serves as the charge nurse for the vascular access team. Ms Eubank has received an Impact Award from Texas Christian University for her work on an evidence-based project focused on midline use in difficult access patients. Richard Kim, MD, is a board-certified internal, pulmonary, and critical care medicine physician in Dallas, Texas. He completed internal medicine residency and a pulmonary and critical care medicine fellowship at the University of Louisville in 2020. He has particular interest in sepsis, point-of-care ultrasound, and pulmonary hypertension
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13
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Atay S, Üzen Cura Ş, Efil S. Nurses' knowledge and experience related to short peripheral venous catheter extravasation. J Vasc Access 2023; 24:848-853. [PMID: 34590526 DOI: 10.1177/11297298211045589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The majority of hospitalized patients receive a Peripheral Venous Catheter (PVC) in the course of their treatment. Extravasation injury is a serious complication of intravenous treatment. OBJECTIVE This cross-sectional survey designed study aims to investigate nurses' knowledge and experience related to short peripheral venous catheter extravasation. METHOD The study sample included 145 nurses working in a university hospital in the west of Turkey. A questionnaire developed in accordance with the literature was used for data collection. The data were assessed by frequency and proportions. RESULTS Of the nurses included in this study, 26.2% reported they had experienced extravasation injury in a patient; 74.5% said they had received no instruction in the management of extravasation during their in-service training program; and 85.5% stated they did not keep a record of extravasation. 89.7% of the nurses reported infused medications as a cause of extravasation, and 81.4% reported catheter sites as a cause. Among the medications reported by the nurses as causing extravasation: 89.7% reported contrast agents; 84.8% TPN solutions; 71.0% cytotoxic agents; and 65.1% mannitol. The symptoms of extravasation reported by nurses included: swelling (97.9%), redness (97.2%), pain (92.4%), rise in temperature (65.5%), and ulceration (60.0%). In responding to the occurrence of extravasation, interventions reported by the nurses included: stopping the flow of fluid (98.6%), elevation (89.7%), cold application (76.6%), and aspiration of drug (40.7%). CONCLUSION Based on these results, it is recommended that guidelines are developed for the management of extravasation, that periodic in-service training programs are provided and that observational studies are carried out into the administration of vesicant drugs.
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Affiliation(s)
- Selma Atay
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
| | - Şengül Üzen Cura
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
| | - Sevda Efil
- Nursing Department at School of Health, Çanakkale Onsekiz Mart University, Canakkale, Turkey
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14
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Coyer B, Carlucci M. Reducing Central Line Utilization by Peripherally Infusing Vasopressors. Dimens Crit Care Nurs 2023; 42:131-136. [PMID: 36996357 DOI: 10.1097/dcc.0000000000000576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Central line-associated bloodstream infection is a preventable contributor to excess death and excess cost in the health care system. Vasopressor infusion is one of the primary reasons for central line placement. In the medical intensive care unit (MICU) at an academic medical center, there was no standard practice for peripheral versus central infusion of vasopressors. OBJECTIVE The objective of this quality improvement project was to implement an evidence-based, nurse-driven protocol to guide the peripheral infusion of vasopressors. The goal was to reduce central line utilization by 10%. METHODS Education on the protocol was provided to the MICU nurses, MICU residents, and crisis nurses, followed by a 16-week implementation period. Nursing staff were also surveyed preimplementation and postimplementation of the protocol. RESULTS Central line utilization was reduced by 37.9%, and there were no central line-associated bloodstream infections recorded during project implementation. Most of the nursing staff indicated that use of the protocol increased their confidence in administering vasopressors without a central line. No significant extravasation events occurred. DISCUSSION Although a causal link between implementation of this protocol and reduction of central line utilization cannot be established, the reduction is clinically meaningful given the known risks of central lines. Increased nursing staff confidence also provides support for continued use of the protocol. CONCLUSION A nurse-driven protocol to guide the peripheral infusion of vasopressors can be effectively implemented into nursing practice.
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15
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Stefanos SS, Kiser TH, MacLaren R, Mueller SW, Reynolds PM. Management of noncytotoxic extravasation injuries: A focused update on medications, treatment strategies, and peripheral administration of vasopressors and hypertonic saline. Pharmacotherapy 2023; 43:321-337. [PMID: 36938775 DOI: 10.1002/phar.2794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 03/21/2023]
Abstract
Extravasation is the leakage of intravenous solutions into surrounding tissues, which can be influenced by drug properties, infusion techniques, and patient-related risk factors. Although peripheral administration of vesicants may increase the risk of extravasation injuries, the time and resources required for central venous catheter placement may delay administration of time-sensitive therapies. Recent literature gathered from the growing use of peripheral vasopressors and hypertonic sodium suggests low risk of harm for initiating these emergent therapies peripherally, which may prevent delays and improve patient outcomes. Physiochemical causes of tissue injury include vasoconstriction, pH-mediated, osmolar-mediated, and cytotoxic mechanisms of extravasation injuries. Acidic agents, such as promethazine, amiodarone, and vancomycin, may cause edema, sloughing, and necrosis secondary to cellular desiccation. Alternatively, basic agents, such as phenytoin and acyclovir, may be more caustic due to deeper tissue penetration of the dissociated hydroxide ions. Osmotically active agents cause cellular damage as a result of osmotic shifts across cellular membranes in addition to agent-specific toxicities, such as calcium-induced vasoconstriction and calcifications or arginine-induced leakage of potassium causing apoptosis. A new category has been proposed to identify absorption-refractory mechanisms of injury in which agents such as propofol and lipids may persist in the extravasated space and cause necrosis or compartment syndrome. Pharmacological antidotes may be useful in select extravasations but requires prompt recognition and frequently complex administration strategies. Historically, intradermal phentolamine has been the preferred agent for vasopressor extravasations, but frequent supply shortages have led to the emergence of terbutaline, a β2 -agonist, as an acceptable alternative treatment option. For hyperosmolar and pH-related mechanisms of injuries, hyaluronidase is most commonly used to facilitate absorption and dispersion of injected agents. However, extravasation management is largely supportive and requires a protocolized multidisciplinary approach for early detection, treatment, and timely surgical referral when required to minimize adverse events.
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Affiliation(s)
- Sylvia S Stefanos
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Scott W Mueller
- Department of Pharmacy, University of Colorado Health, Aurora, Colorado, USA
| | - Paul M Reynolds
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
- Department of Pharmacy, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
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16
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Anomelechi E, Hirst R. Adrenaline-induced hypotension in the context of significant quetiapine overdose. Clin Case Rep 2023; 11:e7117. [PMID: 36937626 PMCID: PMC10017399 DOI: 10.1002/ccr3.7117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 02/21/2023] [Accepted: 03/04/2023] [Indexed: 03/18/2023] Open
Abstract
In patients presenting with hypotension due to significant quetiapine or mixed overdose, adrenaline should be avoided and consider medications such as noradrenaline or vasopressin as an alternative. If using noradrenaline peripherally, use a lower concentration (4 mg in 50 mL 5% glucose) and use a large bore cannula in a large vein.
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Affiliation(s)
| | - Robert Hirst
- Emergency DepartmentUniversity Hospitals Bristol and WestonBristolUK
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17
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García-Uribe J, Lopera-Jaramillo D, Gutiérrez-Vargas J, Arteaga-Noriega A, Bedoya O. Efectos adversos relacionados con la administración de norepinefrina por accesos venosos periféricos cortos: una revisión de alcance. ENFERMERIA INTENSIVA 2023. [DOI: 10.1016/j.enfi.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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18
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Nikhila T, Mohan PL, Mohammed Salim K, Aravind RS. Intravenous cannula induced phlebitis in a tertiary care referral hospital: A prospective observational study with implication from patient's feedback system. J Healthc Qual Res 2022; 37:357-365. [PMID: 35697599 DOI: 10.1016/j.jhqr.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 04/01/2022] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Medicines delivered directly to systemic circulation have saved many lives from life-threatening conditions, but also can impart undesirable effects. MATERIALS AND METHODS A prospective observational study was performed for 10 months in the tertiary care hospital to identify and evaluate cannula induced phlebitis in our study population. The data collection form retrieved demographic details, diseases and cannulation particulars of each patient. Moreover, a patient feedback questionnaire (Cronbach's alpha=0.70) retrieved their concerns toward cannulation. RESULTS Phlebitis was identified in 96 patients out of 146 subjects enrolled in the study; 52% had the first sign of phlebitis. Female patients were more prone, and the complication occurred irrespective of age (p>0.05). On the other hand, those on IV cefoperazone-sulbactam (n=13, 13.5%) followed by amoxicillin clavulanic acid (n=6, 6%) had significant cannulation complication (p<0.01). The cannula indwells time (p=0.001) and vein assessment (p=0.001) were statistically associated with incidence of phlebitis. Half of our samples had pain lasting about five minutes (χ2=9.2, p<0.05). Nevertheless, limited patients (n = 35, 36.5%) were prescribed topical Heparin Benzyl Nitrate, and none preferred to self-medicate nor opted for other home remedies. CONCLUSIONS The study depicted high prevalence of phlebitis factored in by poor vein assessment and increase in indwelling time. We recommend proper awareness with on-site skill improvement program for health professionals on administration techniques and monitoring principles in order to lower cannulation related complications.
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Affiliation(s)
- T Nikhila
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Kerala University of Health Sciences, Kerala, India
| | - P L Mohan
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Kerala University of Health Sciences, Kerala, India
| | - K Mohammed Salim
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Kerala University of Health Sciences, Kerala, India.
| | - R S Aravind
- Department of Pharmacy, Zulekha Hospital, Dubai, United Arab Emirates
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19
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Hunter S, Considine J, Manias E. The influence of intensive care unit culture and environment on nurse decision‐making when managing vasoactive medications: A qualitative exploratory study. J Clin Nurs 2022. [DOI: 10.1111/jocn.16561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Stephanie Hunter
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation Deakin University Geelong Victoria Australia
- Eastern Health Centre for Quality and Patient Safety Research – Eastern Health Partnership Box Hill Victoria Australia
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation Deakin University Geelong Victoria Australia
- Eastern Health Centre for Quality and Patient Safety Research – Eastern Health Partnership Box Hill Victoria Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research in the Institute for Health Transformation Deakin University Geelong Victoria Australia
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20
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Pradhan RR. Inadvertent extravasations of norepinephrine. Clin Case Rep 2022; 10:e6516. [PMID: 36285034 PMCID: PMC9587505 DOI: 10.1002/ccr3.6516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/03/2022] [Accepted: 10/09/2022] [Indexed: 11/11/2022] Open
Abstract
A male patient of diabetic ketoacidosis and septic shock was started on norepinephrine infusion following which he developed bulla and subcutaneous tissue ischemia in the event of inadvertent extravasations of norepinephrine. The patient improved after management with mechanical debridement of necrosed tissue and regular dressing of the wound. The use of higher concentration of norepinephrine via peripheral intravenous route may lead to vasoconstriction and subcutaneous tissue ischemia due to inadvertent extravasations.
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Affiliation(s)
- Ravi Ranjan Pradhan
- Department of Internal MedicineMadesh Institute of Health SciencesJanakpurdhamNepal
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21
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Quinn E, Su J, Fei L, Liu J, Friedman M, Lobel D, Kabiriti S, Likourezos A, Motov S, Eng D. Perceptions and Barriers to Administering Vasopressors in the Prehospital Setting. Cureus 2022; 14:e29614. [PMID: 36321024 PMCID: PMC9603066 DOI: 10.7759/cureus.29614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction Vasopressor administration is a critical medical intervention for patients with hypotension in undifferentiated shock states. Over the years, prehospital care has advanced with protocols and training that allow paramedics in the field to administer a variety of vasopressors. The primary objective of this investigation was to evaluate vasopressor experience among paramedics with regard to preference as well as the barriers to its preparation and administration. Methods A cross-sectional survey of vasopressor use by nationally certified paramedics (NRPs) was performed. A 20-item questionnaire was constructed to capture the prehospital perceptions and barriers of dopamine infusion, norepinephrine infusion, and IV bolus “push-dose” epinephrine (PD-E). Data collection was carried out from June to September 2021. Results A total of 44 responses were obtained (response rate = 44%). All participants had experience using vasopressors and understood their medical indications. Overall, PD-E was the most common vasopressor used in the prehospital setting, and participants felt equally confident in “using” and “preparing” it. Participants felt less confident with “using” and “preparing” vasopressors that required channel setup and maintaining a flow rate. Younger paramedics with less than five years of experience were more eager to use norepinephrine if trucks were stocked with pre-mixed norepinephrine rather than the current formulation that required compounding. Conclusion This study provided preliminary data that evaluated perceptions of vasopressor use in the prehospital setting among paramedics in a large urban environment. Preference and barriers to its preparation and administration were surveyed. Further research is needed to identify the interventions to reduce barriers and allow paramedics to be less limited by logistical considerations when choosing vasopressors in the prehospital setting.
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22
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Fustiñana A, Yock-Corrales A, Casson N, Galvis L, Iramain R, Lago P, Da Silva APP, Paredes F, Zamarbide MP, Aprea V, Kohn-Loncarica G. Adherence to Pediatric Sepsis Treatment Recommendations at Emergency Departments: A Multicenter Study in Latin America. Pediatr Emerg Care 2022; 38:e1496-e1502. [PMID: 35802481 DOI: 10.1097/pec.0000000000002801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20-60 minutes) and 40 minutes (IQR, 20-60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30-135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59-278 minutes] vs 42 minutes [30-70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.
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23
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Bima P, Orlotti C, Smart OG, Morello F, Trunfio M, Brazzi L, Montrucchio G. Norepinephrine may improve survival of septic shock patients in a low-resource setting: a proof-of-concept study on feasibility and efficacy outside the Intensive Care Unit. Pathog Glob Health 2022; 116:389-394. [PMID: 35138990 PMCID: PMC9387336 DOI: 10.1080/20477724.2022.2038051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Septic shock treatment in sub-Saharan African hospitals is challenging due to limited availability of ICUs, central venous catheters, vasopressors, and trained staff. We designed this proof-of-concept study to determine efficacy, safety, and feasibility of norepinephrine (NE) use in a non-intensive setting in a low-resource country, consisting in a peripheral infusion via a mechanical drop counter. Septic shock patients accessing a rural hospital in Uganda were included: the 2020 group (N = 12) was prospectively enrolled (Jan-Mar 2020) when NE was available; the 2019 group (N = 11) was retrospectively enrolled (Oct-Dec 2019). Enrollment was continuous to reduce selection bias. Basic clinical endpoints (noninvasive blood pressure, tissue perfusion, diuresis) defined shock control and the prognostic endpoint was survival at hospital discharge. Shock control at 6 and 12 hours was higher in the 2020 group (p = 0.012 for both). Survival at hospital discharge was 75% and 27.3%, respectively (p = 0.039). NE infusion was associated with a Hazard Ratio of 0.23 (p = 0.041) in a multivariate Cox model. No NE-induced adverse effects were detected. These preliminary results suggest that implementing NE infusion in a low-resource setting without ICU could be a safe and effective strategy in managing septic shock and that this approach could lead to a lower mortality rate.
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Affiliation(s)
- Paolo Bima
- S.C. Medicina d’Urgenza U, Molinette Hospital, A.O.U. Città Della Salute e della Scienza, Torino, Italy,Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, University of Torino, Torino, Italy,CONTACT Paolo Bima S.C. Medicina d’Urgenza U, Molinette Hospital, A.O.U. Città Della Salute e della Scienza, C.so Bramante 88, Torino10126, Italy
| | | | | | - Fulvio Morello
- S.C. Medicina d’Urgenza U, Molinette Hospital, A.O.U. Città Della Salute e della Scienza, Torino, Italy,Department of Medical Sciences, Università degli Studi di Torino, Torino, Italy
| | - Mattia Trunfio
- Infectious Diseases Unit, Department of Medical Sciences, University of Torino, Amedeo di Savoia Hospital, Torino, Italy
| | - Luca Brazzi
- Anestesia e Rianimazione 1U, Department of Anesthesia, Intensive Care and Emergency, A.O.U. Città della Salute e della Scienza, Torino, Italy,Department of Surgical Sciences, University of Torino, Italy
| | - Giorgia Montrucchio
- Anestesia e Rianimazione 1U, Department of Anesthesia, Intensive Care and Emergency, A.O.U. Città della Salute e della Scienza, Torino, Italy,Department of Surgical Sciences, University of Torino, Italy
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24
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Nath SS, Nachimuthu N. Viewpoint: Weak Scientific Basis for the Recommendation of Executive Summary of Surviving Sepsis Campaign Guidelines 2021. Indian J Crit Care Med 2022; 26:898-899. [PMID: 36042756 PMCID: PMC9363812 DOI: 10.5005/jp-journals-10071-24277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Soumya Sankar Nath
- Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
- Soumya Sankar Nath, Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 9648935430, e-mail:
| | - Nandhini Nachimuthu
- Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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25
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Evaluation of Peripheral Administration of 10% Calcium Chloride in a Retrospective, Single-Center Electronic Health Record Cohort. J Emerg Nurs 2022; 48:484-491. [PMID: 35787779 DOI: 10.1016/j.jen.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/11/2021] [Accepted: 12/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Calcium chloride is commonly used in emergency departments in the treatment of a variety of emergencies. Historically, administration via central venous catheters has been preferred owing to its high osmolarity and vesicant properties. Although preferred, central access may not always be available in time-sensitive, emergent situations leading to many instances of peripheral administration. The objective of this analysis was to evaluate the charted safety of peripheral venous administration of 10% calcium chloride. METHODS A single-center retrospective chart review was performed in patients who received 10% calcium chloride in the adult emergency department evaluating for the incidence of infusion-related adverse events. Patients were excluded if they were less than 18 years of age or had a lack of catheter documentation during 10% calcium chloride administration or if the 10% calcium chloride was documented as given through a central venous catheter. RESULTS A total of 72 administrations were evaluated. Patients were predominantly male (67%), with a median age of 55 years and body mass index of 29.2. The primary outcome demonstrated that 4 infusion-related adverse events occurred (6%) with grade 1 (n = 1) and grade 0 (n = 3) documented incidence of infusion-related adverse events. None of the documented incidence of infusion-related adverse events resulted in permanent tissue injury, and all patients had conservative management. DISCUSSION This study demonstrated that administration of 10% calcium chloride via peripheral venous catheters may be feasible and seemed to carry a low incidence of documented complications. Further prospective studies are needed to confirm study observations.
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26
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Block JM, Boateng A, Madhok J. Things We Do for No Reason TM : Mandatory central venous catheter placement for initiation of vasopressors. J Hosp Med 2022; 17:565-568. [PMID: 35820039 DOI: 10.1002/jhm.12844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 04/26/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Jason M Block
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Adjoa Boateng
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jai Madhok
- Department of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, California, USA
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Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022; 26:811-815. [PMID: 36864853 PMCID: PMC9973174 DOI: 10.5005/jp-journals-10071-24243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Septic shock is commonly treated in the emergency department (ED) with vasopressors. Prior data have shown that vasopressor administration through a peripheral intravenous line (PIV) is feasible. Objectives To characterize vasopressor administration for patients presenting to an academic ED in septic shock. Materials and methods Retrospective observational cohort study evaluating initial vasopressor administration for septic shock. ED patients from June 2018 to May 2019 were screened. Exclusion criteria included other shock states, hospital transfers, or heart failure history. Patient demographics, vasopressor data, and length of stay (LOS) were collected. Cases were grouped by initiation site: PIV, ED placed central line (ED-CVL), or tunneled port/indwelling central line (Prior-CVL). Results Of the 136 patients identified, 69 were included. Vasopressors were initiated via PIV in 49%, ED-CVL in 25%, and prior-CVL in 26%. The time to initiation was 214.8 minutes in PIV and 294.7 minutes in ED-CVL (p = 0.240). Norepinephrine predominated all groups. No extravasation or ischemic complications were identified with PIV vasopressor administration. Twenty-eight-day mortality was 20.6% for PIV, 17.6% for ED-CVL, and 61.1% for prior-CVL. Of 28-day survivors, ICU LOS was 4.44 for PIV and 4.86 for ED-CVL (p = 0.687), while vasopressor days were 2.26 for PIV and 3.14 for ED-CVL (p = 0.050). Conclusion Vasopressors are being administered via PIVs for ED septic shock patients. Norepinephrine comprised the majority of initial PIV vasopressor administration. There were no documented episodes of extravasation or ischemia. Further studies should look at the duration of PIV administration with potential avoidance of central venous cannulation altogether in appropriate patients. How to cite this article Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022;26(7):811-815.
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Affiliation(s)
- Scott Kilian
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, United States of America
| | - Aaron Surrey
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America
| | - Weston McCarron
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, United States of America
| | - Kristen Mueller
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America
| | - Brian Todd Wessman
- Department of Anesthesiology and Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America,Brian Todd Wessman, Department of Anesthesiology and Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America, Phone: +13143628538, e-mail:
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28
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First-line Vasopressor Use in Septic Shock and Route of Administration: An Epidemiologic Study. Ann Am Thorac Soc 2022; 19:1713-1721. [PMID: 35709214 DOI: 10.1513/annalsats.202203-222oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Norepinephrine is a first-line agent for treatment of hypotension in septic shock. However, its frequency of use, and potential barriers to its use are unclear. OBJECTIVES To evaluate the frequency of use of norepinephrine in septic shock, to identify potential barriers to its use, and to evaluate trends in use of vasopressors over time. METHODS Retrospective population-based cohort study of patients with septic shock in Alberta, Canada between July 1, 2012 and December 31, 2018. The primary outcome was receipt of a first-line vasopressor other than norepinephrine ("non-norepinephrine vasopressor"). Predictors of receiving a non-norepinephrine vasopressor were assessed using a multivariable-adjusted, multilevel logistic regression model with intensive care unit (ICU) as a random effect. RESULTS Among 6343 patients with septic shock, the proportion of patients receiving non-norepinephrine vasopressors as first-line treatment decreased steadily from 11.5% in 2012 to 3.0% in 2018. Two factors most strongly associated with their receipt were having peripheral intravenous access only (adjusted odds ratio (aOR) 6.15, 95% confidence interval (CI) 4.58-8.26, p<0.001) and year of admission (aOR 0.74 per year after 2012, 95% CI 0.69-0.80, p<0.001). Other factors that had associations after adjustment included admission to a non-teaching hospital (aOR 2.19, 95% CI 1.23-3.89, p=0.007), admission to a coronary care unit (aOR 2.56, 95% CI 1.001-6.54, p=0.05), SOFA score (aOR 0.92 per unit increase, 95% CI 0.88-0.96, p<0.001) and heart rate (aOR 0.92 per 10 beat per minute increase, 95% CI 0.87-0.97, p=0.002). CONCLUSIONS In a large cohort of patients in Alberta, Canada, we found a steady decrease in use of first-line vasopressors other than norepinephrine in septic shock. The strongest factor associated with their use was the presence of only peripheral venous access, suggesting this may still be considered a barrier to administration of norepinephrine.
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29
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Marques CG, Mwemerashyaka L, Martin K, Tang O, Uwamahoro C, Ndebwanimana V, Uwamahoro D, Moretti K, Sharma V, Naganathan S, Jing L, Garbern SC, Nkeshimana M, Levine AC, Aluisio AR. Utilisation of peripheral vasopressor medications and extravasation events among critically ill patients in Rwanda: A prospective cohort study. Afr J Emerg Med 2022; 12:154-159. [PMID: 35505668 PMCID: PMC9046616 DOI: 10.1016/j.afjem.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/14/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction In high-income settings, vasopressor administration to treat haemodynamic instability through a central venous catheter (CVC) is the preferred standard. However, due to lack of availability and potential for complications, CVCs are not widely used in low- and middle-income countries. This prospective cohort study evaluated the use of peripheral vasopressors and associated incidence of extravasation events in patients with haemodynamic instability at the Centre Hospitalier Universitaire Kigali, Rwanda. Methods Patients ≥18 years of age receiving peripheral vasopressors in the emergency centre (EC) or intensive care unit (ICU) for >1 hour were eligible for inclusion. The primary outcome was extravasation events. Patients were followed hourly until extravasation, medication discontinuation, death, or CVC placement. Extravasation incidence with 95% confidence intervals (CI) were calculated using Poisson exact tests. Results 64 patients were analysed. The median age was 49 (Interquartile Range [IQR]:33-65) and 55% were female. Distributive shock was the most frequent aetiology (47%). Intravenous (IV) location was most commonly antecubital fossa/upper arm (31%) and forearm/hand (43%). IV gauges ≤18 were used in 58% of locations. Most patients were treated with adrenaline (66%) and noradrenaline (41%), and 11% received multiple vasopressors. The median treatment duration was 19 hours (IQR:8.5-37). Treatment discontinuation was predominantly due to mortality (41%) or resolution of instability (36%). There were two extravasation events (2.9%), both limited to soft tissue swelling. Extravasation incidence was 0.8 events per 1000 patient-hours (95% CI:0.2-2.2). Conclusion Extravasation incidence with peripheral vasopressors was low, even with long use durations, suggesting peripheral infusions may be an acceptable approach when barriers exist to CVC placement.
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Affiliation(s)
- Catalina G. Marques
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA USA
- Corresponding author.
| | - Lucien Mwemerashyaka
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Kyle Martin
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
| | - Oliver Tang
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Chantal Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Vincent Ndebwanimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Doris Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Katelyn Moretti
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Vinay Sharma
- Michigan State University College of Human Medicine, East Lansing, Michigan USA
| | - Sonya Naganathan
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Ling Jing
- Case Western Reserve University School of Medicine, Cleveland, Ohio USA
| | - Stephanie C. Garbern
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Menelas Nkeshimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, University of Rwanda, Kigali, Rwanda
| | - Adam C. Levine
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
| | - Adam R. Aluisio
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, RI USA
- Brown University Warren Alpert Medical School, Providence, RI USA
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30
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Marti K, Hartley C, Sweeney E, Mah J, Pugliese N. Evaluation of the safety of a novel peripheral vasopressor pilot program and the impact on central line placement in medical and surgical intensive care units. Am J Health Syst Pharm 2022; 79:S79-S85. [PMID: 35605137 PMCID: PMC9384090 DOI: 10.1093/ajhp/zxac144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose The purpose of this quality improvement project was to evaluate the safety and feasibility of peripheral vasopressor administration in an attempt to minimize the placement and improve early removal of unnecessary central lines to reduce central line–associated bloodstream infection (CLABSI) rates. Methods A retrospective chart review was conducted on patients who received vasopressors via peripheral infusion over 3 months, starting at the time of guideline implementation. Results We identified 129 vasopressor orders among 79 patients that were administered peripherally. Among these orders, 3 events were documented as possible extravasation events. Forty-five patients (57%) did not require central line placement due to increasing vasopressor requirements. Standard utilization ratio data suggest minimal central line impact of the protocol implementation. December 2020 to February 2021 was associated with a large second peak of coronavirus disease 2019 (COVID-19) in our region. Utilization of central lines was less than predicted in December 2020 to February 2021 in 2 of our 3 intensive care units (ICUs); however, the differences were statistically significant on only 3 occasions. In the third ICU, utilization was greater than predicted, but this unit housed a majority of the most critically ill patients with COVID-19. Conclusion This study suggests that short-term use of select vasopressors at conservative doses is safe for peripheral administration and points toward efficacy at preventing central line placement. Further analysis is required to confirm efficacy.
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Affiliation(s)
- Kristen Marti
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT, USA
| | | | - Elizabeth Sweeney
- Department of Surgical Critical Care, Hartford Hospital, Hartford, CT, USA
| | - John Mah
- Department of Surgical Critical Care, Hartford Hospital, Hartford, CT.,University of Connecticut School of Medicine, Farmington, CT, USA
| | - Nicholas Pugliese
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT.,University of Connecticut School of Pharmacy, Storrs, CT, USA
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Safety of Vasopressor Medications through Peripheral Line in Pediatric Patients in PICU in a Resource-Limited Setting. Crit Care Res Pract 2022; 2022:6160563. [PMID: 35402044 PMCID: PMC8991380 DOI: 10.1155/2022/6160563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/10/2021] [Accepted: 02/12/2022] [Indexed: 12/12/2022] Open
Abstract
Objective Central venous catheter (CVC) placement in children in resource-limited settings (RLSs) can be a difficult task. Timely administration of vasopressor medications (VMs) through peripheral intravenous line (PIV) can help overcome this limitation. We aim to determine the safety of administration of vasopressor medications through PIVs in children admitted to pediatric intensive care unit (PICU) in a RLS. Design Prospective observational study. Setting. An eight-bedded PICU of a tertiary care hospital. Patients. Children aged 1 month to 18 years admitted to the PICU. Intervention. None. Measurements and Main Results. All children (aged 1 month–18 years) who received VMs through PIV line from January 2019 to December 2019 were prospectively followed for the development of extravasation, conversion to CVC, duration of infusion, maximum dose of VMs used, maximum vasopressor inotropic score (VIS), and coadministration of vasopressor medication through PIV line. Results are presented as means with standard deviation and frequency with percentages. A total of 369 patients were included in the study, 221 (59.9%) were males, and the median age of the study population was 24 months (IQR; 6–96). Epinephrine was the most frequently used vasopressor medication (n = 279, 75.6%), followed by milrinone (n = 93, 25.2%), norepinephrine (n = 42, 11.4%), and dopamine (n = 32, 8.7%). The maximum dose of vasopressor medication was 0.25 µg/kg/min (epinephrine), 0.2 µg/kg/min (norepinephrine), 15 µg/kg/min (dopamine), and 0.8 µg/kg/min (milrinone). Extravasation was observed in 8 (2.2%) patients, while PIV line was converted to CVC in 127 (34.4%) children. Maximum dose of epinephrine, norepinephrine, VIS score, and PRISM Score was associated with conversion to CVC (p < 0.001), while none of them was associated with risk for extravasation. Conclusion Vasopressor medication through PIV line is a safe option in patients admitted to the PICU.
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32
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Bahl A, Hijazi M, Chen NW. Vesicant infusates are not associated with ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing data. PLoS One 2022; 17:e0262793. [PMID: 35085318 PMCID: PMC8794136 DOI: 10.1371/journal.pone.0262793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 12/22/2021] [Indexed: 11/29/2022] Open
Abstract
Background Intravenous vesicants are commonly infused via peripheral intravenous catheters (PIVC) despite guidelines recommending administration via central route. The impact of these medications on PIVC failure is unclear. We aimed to assess dose-related impact of these caustic medications on ultrasound-guided (US) PIVC survivorship. Methods We performed a secondary analysis of a randomized control trial that compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. This study involved reviewing and recording all vesicants infusions through the PIVCs. Type and number of vesicants doses were extracted and characterized as one, two or multiple. The most commonly used vesicants were individually categorized for further analysis. The primary outcome was PIVC failure accounting for use and timing of vesicant infusates. Results Between October 2018 and March 2019, 257 subjects were randomized with 131 in the UL group and 126 in the SL group. Vesicants were infused in 96 (37.4%) out of 257 study participants. In multivariable time-dependent extended Cox regression analysis, there was no significant increased risk of failure due to vesicant use [adjusted hazard ratio, aHR 1.71 (95% CI 0.76–1.81) p = 0.477]. The number of vesicant doses was not significantly associated with the increased risk of PIVC failure [(1 vs 0) aHR 1.20 (95% CI 0.71–2.02) p = 0.500], [(2 vs 0) aHR 1.51 (95% CI 0.67–3.43) p = 0.320] and [(≥ 3 vs 0) aHR 0.98 (95% CI 0.50–1.92) p = 0.952]. Conclusion Vesicant usage did not significantly increase the risk of PIVC failure even when multiple doses were needed in this investigation. Ultrasound-guided PIVCs represent a pragmatic option when vesicant therapy is anticipated. Nevertheless, it is notable that overall PIVC failure rates remain high and other safety events related to vesicant use should be considered when clinicians make vascular access decisions for patients.
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Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan, United States of America
- * E-mail:
| | - Mahmoud Hijazi
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, United States of America
| | - Nai-Wei Chen
- Department of Biostatistics, Beaumont Hospital, Royal Oak, Michigan, United States of America
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33
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Kohn-Loncarica G, Hualde G, Fustiñana A, Monticelli MF, Reinoso G, Cortéz M, Segovia L, Mareco-Naccarato G, Rino P. Use of Inotropics by Peripheral Vascular Line in the First Hour of Treatment of Pediatric Septic Shock: Experience at an Emergency Department. Pediatr Emerg Care 2022; 38:e371-e377. [PMID: 33214518 DOI: 10.1097/pec.0000000000002295] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Mortality in pediatric septic shock remains unacceptably high. Delays in vasopressor administration have been associated with an increased risk of mortality. Current treatment guidelines suggest the use of a peripheral vascular line (PVL) for inotropic administration in fluid-refractory septic shock when a central vascular line is not already in place. The aim of this study was to report local adverse effects associated with inotropic drug administration through a PVL at a pediatric emergency department setting in the first hour of treatment of septic shock. METHODS A prospective, descriptive, observational cohort study of patients with septic shock requiring PVL inotropic administration was conducted at the pediatric emergency department of a tertiary care pediatric hospital. For the infusion and postplacement care of the PVL for vasoactive drugs, an institutional nursing protocol was used. RESULTS We included 49 patients; 51% had an underlying disease. Eighty-four percent of the children included had a clinical "cold shock." The most frequently used vasoactive drug was epinephrine (72%). One patient presented with local complications. CONCLUSIONS At our center, infusion of vasoactive drugs through a PVL was shown to be safe and allowed for adherence to the current guidelines for pediatric septic shock.
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34
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Chebl RB, Kattouf N, Assaf M, Haidar S, Dagher GA, Nabi SA, Bachir R, Sayed ME. Comparing the demographic data and outcomes of septic shock patients presenting to teaching or non-teaching metropolitan hospitals in the United States. World J Emerg Med 2022; 13:433-440. [PMID: 36636570 PMCID: PMC9807389 DOI: 10.5847/wjem.j.1920-8642.2022.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/14/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Studies looking at the effect of hospital teaching status on septic shock related in-hospital mortality are lacking. The aim of this study was to examine the effect of hospital teaching status on mortality in septic shock patients in the United States. METHODS This was a retrospective observational study, using the Nationwide Emergency Department Sample Database (released in 2018). All patients with septic shock were included. Complex sample logistic regression was performed to assess the impact of hospital teaching status on patient mortality. RESULTS A total of 388,552 septic shock patients were included in the study. The average age was 66.93 years and 51.7% were males. Most of the patients presented to metropolitan teaching hospitals (68.2%) and 31.8% presented to metropolitan non-teaching hospitals. Septic shock patients presenting to teaching hospitals were found to have a higher percentage of medical comorbidities, were more likely to be intubated and placed on mechanical ventilation (50.5% vs. 46.9%) and had a longer average length of hospital stay (12.47 d vs. 10.20 d). Septic shock patients presenting to teaching hospitals had greater odds of in-hospital mortality compared to those presenting to metropolitan non-teaching hospitals (adjusted odd ratio [OR]=1.295, 95% confidence interval [CI]: 1.256-1.335). CONCLUSION Septic shock patients presenting to metropolitan teaching hospitals had significantly higher risks of mortality than those presenting to metropolitan non-teaching hospitals. They also had higher rates of intubation and mechanical ventilation as well as longer lengths of hospital stay than those in non-teaching hospitals.
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Affiliation(s)
- Ralph Bou Chebl
- Department of Emergency Medicine, American University of Beirut, Beirut 1107 2020, Lebanon,Corresponding Author: Ralph Bou Chebl,
| | - Nadim Kattouf
- Department of Emergency Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Mohamad Assaf
- Department of Emergency Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Saadeddine Haidar
- Department of Emergency Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Gilbert Abou Dagher
- Department of Emergency Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Sarah Abdul Nabi
- Department of Emergency Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Rana Bachir
- Department of Emergency Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
| | - Mazen El Sayed
- Department of Emergency Medicine, American University of Beirut, Beirut 1107 2020, Lebanon
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35
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Ragoonanan D, Friedman L. Clinical Update on Vasopressors and Titration Strategies. AACN Adv Crit Care 2021; 32:369-374. [PMID: 34879131 DOI: 10.4037/aacnacc2021106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- David Ragoonanan
- David Ragoonanan is Critical Care Pharmacist, Sarasota Memorial Hospital, 1700 S Tamiami Trail, Sarasota, FL 34239
| | - Lyudmila Friedman
- Lyudmila Friedman is Critical Care Pharmacist, Tampa General Hospital, Tampa, Florida
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36
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Bou Chebl R, Kattouf N, Assaf M, Abou Dagher G, Kassir A, Mahmassani D, Bachir R, El Sayed M. The Weekend Effect in Septic Shock Patients Using the Nationwide Emergency Department Sample Database. Shock 2021; 56:910-915. [PMID: 33651724 DOI: 10.1097/shk.0000000000001766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The weekend effect is the increased mortality in hospitalized patients admitted on the weekend. The aim of this study was to examine the effect of weekend admissions on septic shock patients. METHODS This is a retrospective observational study of the 2014 Nationwide Emergency Department Sample Database. Septic shock patients were included in this study using ICD-9-CM codes. Descriptive analysis was done, in addition to bivariate analysis to compare variables based on admission day. Multivariate analysis was conducted to examine the association between admission day and mortality in septic shock patients after adjusting for potential confounding factors. RESULTS A total of 364,604 septic shock patients were included in this study. The average age was 67.19 years, and 51.1% were males. 73.0% of patients presented on weekdays. 32.3% of septic shock patients died during their hospital stay. After adjusting for confounders, there was no significant difference in the emergency department or in-hospital mortality of septic shock patients admitted on the weekend compared with those admitted during weekdays, (OR = 1.00 [95% CI: 0.97-1.03], P value = 0.985). CONCLUSION There was no statistically significant difference in overall mortality between septic shock patients admitted on the weekend or weekday. Our results are contradictory to previous studies showing an increased mortality with the weekend effect. The previous observations that have been made may not stand up with current treatment protocols.
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Affiliation(s)
- Ralphe Bou Chebl
- Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon
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37
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Farhat R, Minoff J, Burke S, Patolia S. Recommended Reading from Saint Louis University School of Medicine Fellows. Am J Respir Crit Care Med 2021; 204:1473-1475. [PMID: 34699334 DOI: 10.1164/rccm.202103-0685rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Rania Farhat
- Saint Louis University, 7547, Saint Louis, Missouri, United States
| | - Jennifer Minoff
- Saint Louis University, 7547, Saint Louis, Missouri, United States
| | - Shannon Burke
- Saint Louis University, 7547, Saint Louis, Missouri, United States
| | - Setu Patolia
- Saint Louis University, 7547, Pulmonary and Critical Care, Saint Louis, Missouri, United States;
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38
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Groetzinger LM, Williams J, Svec S, Donahoe MP, Lamberty PE, Barbash IJ. Peripherally Infused Norepinephrine to Avoid Central Venous Catheter Placement in a Medical Intensive Care Unit: A Pilot Study. Ann Pharmacother 2021; 56:773-781. [PMID: 34674566 DOI: 10.1177/10600280211053318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reducing central venous catheter (CVC) utilization can reduce complications in the intensive care unit (ICU). While norepinephrine (NE) is traditionally administered via a CVC, lower concentrations may be safely administered via peripheral intravenous (PIV) lines. OBJECTIVE We aimed to describe the implementation of a pilot protocol utilizing PIVs to administer a low-dose and lower-concentration NE, review the number of CVCs avoided, and evaluate any adverse events. METHODS In a quaternary medical intensive care unit (MICU), from March 1, 2019, to February 29, 2020, we reviewed charts for CVC placement and adverse events from the pNE infusion. We also measured unit-level CVC utilization in all MICU patients and assessed the change in utilization associated with the peripheral norepinephrine (pNE) protocol. RESULTS Over a 1-year period, 87 patients received a pNE infusion. Overall, 44 patients (51%) never required CVC placement during their MICU stay. Three patients (3%) experienced adverse events, none of which were documented as serious and or required antidote for treatment. Implementation of the protocol was associated with a decrease in the number of patients at the unit level who received CVCs, even if they did not receive pNE. CONCLUSION AND RELEVANCE In this small pilot study, we pragmatically demonstrated that pNE is safe and may reduce the need for CVC placement. This information can be used to aid in pNE protocol development and implementation at other institutions, but further research should be done to confirm the safety of routine use of pNE in clinical practice.
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Affiliation(s)
| | - Julia Williams
- Department of Nursing, UPMC Presbyterian Hospital, Pittsburgh, PA, USA
| | - Susan Svec
- Department of Nursing, UPMC Presbyterian Hospital, Pittsburgh, PA, USA
| | - Michael P Donahoe
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Phillip E Lamberty
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ian J Barbash
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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39
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Stolz A, Efendy R, Apte Y, Craswell A, Lin F, Ramanan M. Safety and efficacy of peripheral versus centrally administered vasopressor infusion: A single-centre retrospective observational study. Aust Crit Care 2021; 35:506-511. [PMID: 34600834 DOI: 10.1016/j.aucc.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 08/12/2021] [Accepted: 08/22/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Shock affects one-third of patients admitted to intensive care and is associated with increased mortality. Vasopressor medications are used to maintain blood pressure in shock. Central venous catheters are associated with serious complications and pose logistical difficulties for insertion. Delivery of vasopressors via peripheral intravenous cannula may be a safe alternative. METHODS This is a retrospective cohort study comparing safety profile and outcomes of vasopressor delivery via peripheral and central routes in critically ill patients over a 12-month period in a mixed medical-surgical intensive care unit. Demographics, clinical characteristics, treatments, and safety outcome data were extracted from medical records. Patients were classified into three groups: vasopressor infusions via peripheral intravenous cannula, combined peripheral intravenous cannula followed by central venous catheter, and central venous catheter only. Groups were compared using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. The impact of duration of vasopressor infusion on complication rates was assessed using logistic regression. RESULTS We identified 212 patients who received vasopressor infusion, 39 received via peripheral only (Group 1), 155 via peripheral followed by central (Group 2), and 18 via central only (Group 3). There were some baseline differences between groups. Group 1 had the lowest median Acute Physiology and Chronic Health Evaluation III score (64, interquartile range = 44-77), and Group 3, the highest (86, interquartile range = 57-101). Duration of vasopressor infusion was shortest in Group 1 and longer in Groups 2 and 3. There were no major complications; however, minor complications such as leakage, extravasation, and erythema occurred in 41% of Group 1 and 28% of Group 2 patients. Duration of peripheral vasopressor infusion was not associated with an increased risk of complications. CONCLUSIONS Administration of vasopressor infusions for short duration in critically ill patients via a peripheral venous cannula may be feasible, with low rates of complications, and offers a safe alternative to central venous access.
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Affiliation(s)
- Annaliese Stolz
- Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia
| | | | - Yogesh Apte
- Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia.
| | | | - Frances Lin
- University of the Sunshine Coast, Sunshine Coast Health Institute, Queensland, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia; ICU, The Prince Charles Hospital, Australia; The George Institute & University of NSW, Australia
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40
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„C-Probleme“ des nichttraumatologischen Schockraummanagements. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00936-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
ZusammenfassungIm Rahmen des nichttraumatologischen Schockraummanagements zur Versorgung kritisch kranker Patienten werden akute Störungen der Vitalfunktionen rasch detektiert und behandelt. Beim „primary survey“ (Erstversorgung) dient das etablierte ABCDE-Schema der strukturierten Untersuchung aller relevanten Vitalparameter. Akute Störungen werden hierbei unmittelbar detektiert und therapiert. „C-Probleme“ stellen den größten Anteil der ABCDE-Störungen bei nichttraumatologischen Schockraumpatienten dar und zeichnen sich durch eine hämodynamische Instabilität infolge hypovolämischer, obstruktiver, distributiver oder kardiogener Schockformen aus. Abhängig von den lokalen Versorgungsstrukturen umfasst die nichttraumatologische Schockraumversorgung hierbei auch die Stabilisierung von Patienten mit akutem Koronarsyndrom oder nach prähospitaler Reanimation (Cardiac Arrest Center).
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41
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Haimovich AD, Jiang R, Taylor RA, Belsky JB. Risk factor identification and predictive models for central line requirements for patients on vasopressors. Anaesth Intensive Care 2021; 49:275-283. [PMID: 34392707 DOI: 10.1177/0310057x211024258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vasopressors are ubiquitous in intensive care units. While central venous catheters are the preferred route of infusion, recent evidence suggests peripheral administration may be safe for short, single-agent courses. Here, we identify risk factors and develop a predictive model for patient central venous catheter requirement using the Medical Information Mart for Intensive Care, a single-centre dataset of patients admitted to an intensive care unit between 2008 and 2019. Using prior literature, a composite endpoint of prolonged single-agent courses (>24 hours) or multi-agent courses of any duration was used to identify likely central venous catheter requirement. From a cohort of 69,619 intensive care unit stays, there were 17,053 vasopressor courses involving one or more vasopressors that met study inclusion criteria. In total, 3807 (22.3%) vasopressor courses involved a single vasopressor for less than six hours, 7952 (46.6%) courses for less than 24 hours and 5757 (33.8%) involved multiple vasopressors of any duration. Of these, 3047 (80.0%) less than six-hour and 6423 (80.8%) less than 24-hour single vasopressor courses used a central venous catheter. Logistic regression models identified associations between the composite endpoint and intubation (odds ratio (OR) 2.36, 95% confidence intervals (CI) 2.16 to 2.58), cardiac diagnosis (OR 0.72, CI 0.65 to 0.80), renal impairment (OR 1.61, CI 1.50 to 1.74), older age (OR 1.002, Cl 1.000 to 1.005) and vital signs in the hour before initiation (heart rate, OR 1.006, CI 1.003 to 1.009; oxygen saturation, OR 0.996, CI 0.993 to 0.999). A logistic regression model predicting the composite endpoint had an area under the receiver operating characteristic curve (standard deviation) of 0.747 (0.013) and an accuracy of 0.691 (0.012). This retrospective study reveals a high prevalence of short vasopressor courses in intensive care unit settings, a majority of which were administered using central venous catheters. We identify several important risk factors that may help guide clinicians deciding between peripheral and central venous catheter administration, and present a predictive model that may inform future prospective trials.
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Affiliation(s)
- Adrian D Haimovich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ruoyi Jiang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA.,Yale School of Medicine, New Haven, CT, USA
| | - Richard A Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Justin B Belsky
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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42
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Liu L, Luo L, Li L, Jin M. Safety of high-concentration norepinephrine for peripheral intravenous use. Comment on Br J Anaesth 2020; 124: e108-14. Br J Anaesth 2021; 127:e135-e137. [PMID: 34353613 DOI: 10.1016/j.bja.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/29/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Liwei Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lan Luo
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lu Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Mu Jin
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
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43
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French WB, Rothstein WB, Scott MJ. Time to Use Peripheral Norepinephrine in the Operating Room. Anesth Analg 2021; 133:284-288. [PMID: 33886514 DOI: 10.1213/ane.0000000000005558] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
| | | | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, Virginia.,Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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44
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Zhang Z, A Celi L, Ho KM. Prediction of extended period of vasopressor infusion requiring central venous catheterisation: A burning issue in critical care. Anaesth Intensive Care 2021; 49:250-252. [PMID: 34392691 DOI: 10.1177/0310057x211030927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Hangzhou, China
- Key Laboratory of Emergency and Trauma, Hainan Medical University, Haikou, China
| | - Leo A Celi
- Department of Biostatistics, Harvard T H Chan School of Public Health, Boston, USA
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Kwok M Ho
- Department of Intensive Care Medicine, 6508Royal Perth Hospital, Royal Perth Hospital, Perth, Australia
- Medical School, University of Western Australia, Perth, Australia
- School of Veterinary and Life Sciences, Murdoch University, Perth, Australia
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45
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Ong J, Van Gerpen R. Recommendations for Management of Noncytotoxic Vesicant Extravasations. JOURNAL OF INFUSION NURSING 2021; 43:319-343. [PMID: 33141794 DOI: 10.1097/nan.0000000000000392] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To prepare clinicians to treat extravasation of noncytotoxic vesicants with antidotes and thermal compresses, a literature review was performed to identify noncytotoxic vesicants and to create evidence and consensus-based recommendations. The stage of injury and vesicant's mechanism of tissue injury dictate treatment. For a vasopressor extravasation, warm compresses and administration of a vasodilator are recommended. For osmolarity, pH, absorption refractory, and cytotoxic concentration-dependent vesicants, warm compresses and administration of hyaluronidase are recommended. Compared with potentially catastrophic costs of undertreatment, the cost of overtreatment is minimal.
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Affiliation(s)
- Jennie Ong
- Bryan Medical Center, Lincoln, Nebraska (Dr Ong and Ms Van Gerpen).,Jennie Ong, PharmD, is a clinical pharmacist at Bryan Medical Center in Lincoln, Nebraska, with 10 years of hospital pharmacy experience. Her specialties include formulary management and patient safety-oriented process improvements.,Ruth Van Gerpen MS, RN-BC, APRN-CNS, AOCNS®, is a clinical nurse specialist at Bryan Medical Center in Lincoln, Nebraska, with 36 years of oncology experience. Her subspecialties include pain management and infusion therapy
| | - Ruth Van Gerpen
- Bryan Medical Center, Lincoln, Nebraska (Dr Ong and Ms Van Gerpen).,Jennie Ong, PharmD, is a clinical pharmacist at Bryan Medical Center in Lincoln, Nebraska, with 10 years of hospital pharmacy experience. Her specialties include formulary management and patient safety-oriented process improvements.,Ruth Van Gerpen MS, RN-BC, APRN-CNS, AOCNS®, is a clinical nurse specialist at Bryan Medical Center in Lincoln, Nebraska, with 36 years of oncology experience. Her subspecialties include pain management and infusion therapy
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46
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Alibhai N, Detsky M, Wunsch H, Teja B. Severe Hyponatremia and Seizure From Peripheral Infusion of Norepinephrine Diluted in Dextrose 5% in Water: A Case Report. A A Pract 2021; 15:e01479. [PMID: 33988526 DOI: 10.1213/xaa.0000000000001479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recent studies have demonstrated that vasopressors can be delivered safely through peripheral intravenous lines. While norepinephrine is usually delivered at a concentration of 16 to 32 μg/mL, out of concern for extravasation and interstitial necrosis, some patients receive more dilute norepinephrine solutions through peripheral intravenous catheters. We describe a case of severe hyponatremia and seizure resulting from administration of norepinephrine concentrated at 4 μg/mL in dextrose 5% in water. After the incident, the institutional policy changed to recommend normal saline as the default diluent for peripheral norepinephrine, with a more concentrated option available. The incident also informed similar guidelines at other hospitals.
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Affiliation(s)
- Nafeesa Alibhai
- From the Department of Integrated Sciences: Genetics, Physiology, Neuroscience, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Detsky
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada.,Division of Critical Care Medicine, Department of Medicine and Interdepartmental University of Toronto, Toronto, Ontario, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bijan Teja
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Departments of Anesthesiology and Critical Care Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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47
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Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:146. [PMID: 33863361 PMCID: PMC8050944 DOI: 10.1186/s13054-021-03553-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/26/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is unclear whether vasopressors can be safely administered through a peripheral intravenous (PIV). Systematic review and meta-analysis methodology was used to examine the incidence of local anatomic adverse events associated with PIV vasopressor administration in patients of any age cared for in any acute care environment. METHODS MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials, and the Database of Abstracts of Reviews of Effects were searched without restriction from inception to October 2019. References of included studies and related reviews, as well as relevant conference proceedings were also searched. Studies were included if they were: (1) cohort, quasi-experimental, or randomized controlled trial study design; (2) conducted in humans of any age or clinical setting; and (3) reported on local anatomic adverse events associated with PIV vasopressor administration. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials or the Joanna Briggs Institute checklist for prevalence studies where appropriate. Incidence estimates were pooled using random effects meta-analysis. Subgroup analyses were used to explore sources of heterogeneity. RESULTS Twenty-three studies were included in the systematic review, of which 16 and 7 described adults and children, respectively. Meta-analysis from 11 adult studies including 16,055 patients demonstrated a pooled incidence proportion of adverse events associated with PIV vasopressor administration as 1.8% (95% CI 0.1-4.8%, I2 = 93.7%). In children, meta-analysis from four studies and 388 patients demonstrated a pooled incidence proportion of adverse events as 3.3% (95% CI 0.0-10.1%, I2 = 82.4%). Subgroup analyses did not detect any statistically significant effects associated with stratification based on differences in clinical location, risk of bias or design between studies, PIV location and size, or vasopressor type or duration. Most studies had high or some concern for risk of bias. CONCLUSION The incidence of adverse events associated with PIV vasopressor administration is low. Additional research is required to examine the effects of PIV location and size, vasopressor type and dose, and patient characteristics on the safety of PIV vasopressor administration.
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Ruchti VE, Wibrow BA, Seet J, Jacques A, Jha N, Anstey MH. A prospective comparison of peripheral metaraminol versus dilute noradrenaline in the intensive care unit. Anaesth Intensive Care 2021; 49:144-146. [PMID: 33853391 DOI: 10.1177/0310057x20984794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Vera Ew Ruchti
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Bradley A Wibrow
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia
| | - Jason Seet
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Angela Jacques
- Institute for Health Research, University of Notre Dame, Fremantle, Australia.,Department of Research, Sir Charles Gairdner Hospital, Perth, Australia
| | - Nihar Jha
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Perth, Australia.,School of Medicine, University of Western Australia, Perth, Australia.,School of Public Health, Curtin University Medical School, Perth, Australia
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Yealy DM, Mohr NM, Shapiro NI, Venkatesh A, Jones AE, Self WH. Early Care of Adults With Suspected Sepsis in the Emergency Department and Out-of-Hospital Environment: A Consensus-Based Task Force Report. Ann Emerg Med 2021; 78:1-19. [PMID: 33840511 DOI: 10.1016/j.annemergmed.2021.02.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Indexed: 12/12/2022]
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Tripathi S, Gladfelter T. Peripheral intravenous catheters in hospitalized patients: Practice, Dwell times, and factors impacting the dwell times: A single center retrospective study. J Vasc Access 2021; 23:581-588. [PMID: 33784876 DOI: 10.1177/11297298211000874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite being the most common hospital procedure, limited information is available on the peripheral intravenous (PIV) catheter insertion practices. This study was designed to evaluate the contemporary PIV insertion practice (all age groups), and to identify the patient and device-related factors influencing the dwell times (<18 years). METHODS Single Center Retrospective study. Patients of all age groups admitted to the hospital for >4 midnights, from 01/2015 to 12/2019. Data extracted by automated EMR audits. Variables included patient demographics, number of PIVs inserted, PIV size, location, dwell time, and length of stay. Standard comparative analysis, including multivariable linear regression for dwell time performed for patients <18 years. RESULTS A total of 44,198 (39,341 (89%) adults and 4857 (11%) children) PIVs on unique patients met study criteria, with mean duration of 2.8 ± 2.4 days in children and 2.6 ± 1.3 days in adults (p < 0.001). Pediatric PIV had more dwell time variation, with a higher proportion lasting <1-day and also >2 SD of the age-specific mean, compared to adults. Adults had significantly higher number of PIVs placed/week compared to children. The failure rate for PIV was 56% in children and 76% in adults (p < 0.001). 1 out of 5 adults required >5 PIV/admission. Forty-five percent of children requiring only one PIV versus 21.8% of seniors. Discharge department, body part, and PIV size were independently associated with the dwell duration in children. No PIV size, however, had an independent increase in dwell duration over the reference of the 24 Ga cannula in children. PIVs placed in ante cubital vein and upper arm had dwell duration 26% and 20% longer than PIVs placed in the hand. CONCLUSIONS The failure rate of PIV is high, and patients are subjected to multiple insertions during hospitalization. Hospital unit, body part, and PIV size are associated with the dwell duration in children.
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Affiliation(s)
- Sandeep Tripathi
- Pediatric Critical Care, OSF Saint Francis Medical Centre Peoria, IL, USA
| | - Taylor Gladfelter
- Healthcare Analytics, OSF Saint Francis Medical Centre, Peoria, IL, USA
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