Guidelines for Infusing Vasopressors in a Peripheral Catheter

Q What are the guidelines for infusing vasopressors in a peripheral catheter?A Stephanie Chamberlain, DNP, CNS, ACCNS-AG, CCRN, and Daniell Kempton, MSN, APRN, ACCNS-AG, CCRN-CSC, TCRN, reply:When caring for adult patients who require vasopressor support, it has long been considered ideal to use a central venous access device (CVAD) to ensure the vesicant does not infiltrate and permanently damage tissue and muscle. Despite several studies highlighting that it is safe to infuse vasopressors via peripheral intravenous (PIV) catheters, nurses remain apprehensive about the practice.1–7 In our practice, a PIV catheter is defined as a 2- to 4-cm catheter inserted into a peripheral vein. Additionally, when peripheral vasopressor use does occur, it is done with safety guardrails, guidance, and increased vigilance.Many patients may benefit from the infusion of low-dose peripheral vasopressors for a limited amount of time, thus avoiding the risks of placing and maintaining a CVAD. The Infusion Nurses Society currently states that short-term use (less than 24 hours) of PIV catheters is generally safe, with few adverse events reported. However, the Infusion Nurses Society continues to recommend that more evidence and research are needed to support the use of midline catheters for administration of low-dose vasopressors.8Establishing inclusion and exclusion criteria for your organization is key to having successful peripheral vasopressor practice. Vasopressor use can be found in many areas; however, it is mostly found in emergency departments and intensive care units.Limiting the location of the practice and ensuring an experienced practitioner approves the patient can allow for stronger adherence to the guidelines of the practice. Research and literature show that some locations have a higher risk of extravasation and infiltration—for example, hands and upper biceps.4 This evidence should be taken into consideration when determining where the PIV catheters will be used and if ultrasound-guided catheters will be included. Our institution has found that forearm intravenous catheters allow for increased adherence to the guideline and early detection of infiltration and extravasation. Upper arm PIV catheters, ultrasound-guided catheters, and a larger body habitus can lead to challenging visual examination for infiltration and extravasation.Patients who already have a CVAD for treatments such as dialysis or patients who are unable to have 2 PIV catheters, whether due to difficult vascular access or limb restrictions, should not be included in the peripheral vasopressor practice. Establishing at least 2 PIV catheters allows the bedside staff to have a backup site in case the original catheter fails. An escalation pathway should also be established if both catheters are lost and there is an emergent need for access. Intraosseous access allows for a rapidly placed and confirmed catheter in an emergency. Table 1 shows inclusion and exclusion criteria for administering vasopressors via peripheral catheters.Instituting a comprehensive order set for the infusion of peripheral vasopressors encourages a focus on safety guardrails and provides guidance to bedside nurses on assessments and care. One important safeguard is to provide only appropriate drugs, concentrations, and suggested maximum doses (Table 2). For example, as vasopressin is not considered a first-line drug, it is not included in the list of medications in the order set. Also, during an emergency, nurses are empowered to titrate medications as high as needed while a CVAD is placed.Catheter size should be considered. Although no strong guidance is available regarding catheter size and peripheral administration of vasopressors, existing evidence recommends using a catheter size of 20 g or larger for computed tomography contrast.9 Inclusion of an order set for infiltration treatment may also be helpful for the rapid reversal of extravasations.Nurses should consider increased monitoring of the catheter site for any redness, swelling, or other signs and symptoms of extravasation. For documentation burden reduction, our organization’s order set suggests a visualization of the site every hour, with assessments documented every 4 hours. If signs and symptoms have been identified, nurses should contact a practitioner for next steps and treatment.Working with interprofessional teams increases collaboration and may help prevent communication failures if all stakeholders are engaged. It is essential to consider staff onboardings, resident changes, and leadership transitions when introducing guidelines for a high-risk practice. Additionally, follow-up education may be necessary with new staff and with any deviations from the guidelines.In the first year of implementation of the guidelines, order set, and education, our organization placed more than 700 peripheral catheters for vasopressor use. There were 2 extravasations, which were appropriately treated and did not have further adverse effects. The remaining hospitals in our system have since adopted the guidelines and have had no adverse effects when following the protocol.When monitoring peripheral vasopressor use, nurses should ensure that the standards of care are being followed to prevent patient harm and increase safety. By having clear guidelines, interprofessional support, and well-developed infrastructure, the bedside clinician can optimize patient care by reducing harm from CVAD insertion and risk of extravasation or infiltration. Although Infusion Nurses Society standards do not fully support the use of vasopressors peripherally past the 24-hour mark, they state that more research and literature is needed for determination. Concerns remain about the use of peripheral vasopressors in midline catheters, and more research is required to support that practice.8,10–13 Establishing safety parameters and infrastructure to support clinicians decreases patient safety events, increases knowledge, and adds to the body of literature surrounding peripheral vasopressor use.