Peripheral norepi

[deleted875186]

Picked up an ICU case the other day on peripheral norepi. When asked why norepi versus phenylephrine they didn’t know. Surgeon wanted higher BP goals during the case (clamping carotid ) and I couldn’t get the payient off norepi. I was already up to 200 mcg phenylephrine to try and get him off. They also tucked the arms for which surgery, and made me very uneasy about continuing he peripheral norepi.

Would you have delayed to put a central line in? Or just done the case with peripherals expecting he huh tj not need the pressers indefinitely?

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[d9sccr]

I was listening to ACCRAC a few weeks ago and the host said there's good evidence that dilute norepinephrine is okay through PIV. I haven't seen such evidence personally

 

[coffeebythelake]

It takes one infiltrated IV to change your mind about all this... just saying

 

[anbuitachi]

Picked up an ICU case the other day on peripheral norepi. When asked why norepi versus phenylephrine they didn’t know. Surgeon wanted higher BP goals during the case (clamping carotid ) and I couldn’t get the payient off norepi. I was already up to 200 mcg phenylephrine to try and get him off. They also tucked the arms for which surgery, and made me very uneasy about continuing he peripheral norepi.

Would you have delayed to put a central line in? Or just done the case with peripherals expecting he huh tj not need the pressers indefinitely?

Perhaps they started off w phenylephrine and then requirement went up in the middle of the case so they started norepi. Im fine w peripheral norepi intraoperative. But if it's going to be continued in ICU probably should put a central line

The difference is in the ICU everything is pumped so it can infiltrated and pump will keep pumping. In the OR the norepi on pump Is often carried by an IV drip to gravity so it's easier to tell if your IV no longer works

 

[nimbus]

I put in a central line and an Aline every time I pick up an ICU patient with norepinephrine going through a peripheral line. Half the time those IV’s are crap. Not worth me stressing about infiltration or poor IV access to save 10min.

I always ask myself, “does this make me feel uneasy?” If so I do what it takes to make myself more relaxed. Safer patient=>more relaxed anesthesiologist.

 

[vector2]

If it's an 18 or larger and the arms are out, I would run 2mg or 4mg in 250ml on a pump with a carrier going at 100/hr. High concentration, arms tucked, and it's a 22g in the thumb? No chance.

More importantly, it sounds like you had a sick patient, pressor dependent, who was getting major vascular surgery. This sounds like the kind of guy I would line up regardless of the IV circumstances.

 

[deleted59964]

Would you have delayed to put a central line in?

yes, yes I would - fark that shyte.
that patient wouldn't have got out of icu without an art line and a central line.

 

[pgg]

Depends on the IV.

Infiltration risk in the ICU is higher than it is in the OR. You've got a wiggly patient, possibly delirious, possibly restrained, semi-continuously watched by an RN (if not too busy or distracted and depending on alarms to attract attention).

In contrast, in the OR the patient is absolutely still. If an IV running a vasopressor infiltrates you'll know something is up in a couple minutes when hypotension develops. You're smart enough to know the difference between an 18g that flows like a hose and a 22g sideways spider vein ER special.

 

[AdmiralChz]

There is SOME evidence out there that it’s semi-safe IF frequent IV checks are done. I don’t have access right now but in a hospitalist study they used peripheral norepi (amongst other pressors) and the bedside RN used ultrasound to demonstrate vein latency every 1-2 hours (!!). Also used 18 g or greater.

That being said I’ve seen it infiltrate with a standard 8-16 mcg/mL infusion and it was BAD. It’s extremely caustic to tissues and causes copious necrosis - our hospital’s policy was to mark the area and inject the periphery with Phentolamine to limit the spread. I saw it twice in residency (of course OSH transfers), both required several plastics debridements and one lady nearly lost an arm. I think giving small boluses is probably safe as long as you aren’t going overboard, but if you need a prolonged infusion you should probably place a PICC or CVL.

I’ll see if I can find the reference.

 

[AdmiralChz]

Found this on the internet machine:

https://emcrit.org/wp-content/uploads/2015/07/Mayo-Peripheral-Pressors.pdf

Here they aspirated on the line every couple of hours. Realistically, I don’t see most hospitals/ICUs being this rigorous about IV patency. But interesting none-the-less.

 

[drmwvr]

https://emcrit.org/wp-content/uploads/2015/07/Mayo-Peripheral-Pressors.pdf

Frogging around with the IV by aspirating through it just risks blowing it, draws the medicine out of the vessel, requires a flush, causes a lag time in "catching up" with the blood pressure...Not OK when the arms are tucked and the IV is out of sight.

Peripheral NE in the OR is fine, even with the arms tucked as long as there is a bomb proof IV. That means one that I put in before the arms are tucked. I don't trust PIV's from the ICU for anything, let alone an inopressor. In this case, if there was no good peripheral access, a neck or SC line.

 

[nimbus]

Constantly checking your PIV is for the birds. Easier to insert a central line and be done with it.

 

[fakin' the funk]

Would you have delayed to put a central line in? Or just done the case with peripherals expecting he huh tj not need the pressers indefinitely?

I would run norepinephrine through an not-visible / tucked peripheral IV if it was a GOOD peripheral IV that I put in MYSELF. A good moment to ask yourself, if this was my family member, would I do it?

It's not a "delay" to the case to secure adequate vascular access. It IS the case, especially when the surgeon is demanding the pressor or it's necessary for the pt's pathophysiology. Don't paint yourself into a corner.

Worth mentioning in this setting is that standards for safety and adverse events (like IV infiltrations, critical desats, etc etc) are at least 1 order of magnitude less rigorous in the ICU than they are in anesthesia/OR.

 

[deleted875186]

Good points. I ended up doing the case with the peripherals and an art line. But I was uneasy the whole case. I didn’t think about the arms being tucked before the case started, and in retrospect would have taken the 10 mins upon entering the room to put in a Central line. Probably won’t risk it again unless it’s an emergency.

 

[Robotic Wis-Hipple]

https://emcrit.org/wp-content/uploads/2015/07/Mayo-Peripheral-Pressors.pdf

Frogging around with the IV by aspirating through it just risks blowing it, draws the medicine out of the vessel, requires a flush, causes a lag time in "catching up" with the blood pressure...Not OK when the arms are tucked and the IV is out of sight.

Peripheral NE in the OR is fine, even with the arms tucked as long as there is a bomb proof IV. That means one that I put in before the arms are tucked. I don't trust PIV's from the ICU for anything, let alone an inopressor. In this case, if there was no good peripheral access, a neck or SC line.

I like this answer.

 

[anbuitachi]

Good points. I ended up doing the case with the peripherals and an art line. But I was uneasy the whole case. I didn’t think about the arms being tucked before the case started, and in retrospect would have taken the 10 mins upon entering the room to put in a Central line. Probably won’t risk it again unless it’s an emergency.

Would you have gone subclavian?

 

[deleted171991]

Peripheral vasopressors: the myth and the evidence

"However, actual harms from peripheral vasopressors are actually quite rare, and to really make this decision we have to consider the harms of requiring a central line. Central lines have their own risks, including infections, DVTs, arterial punctures, and pneumothoraces. Furthermore, requiring a central line for vasopressors often results in a delay to necessary therapy. When considering those harms, I think it is clear that the administration of peripheral vasopressors is not only acceptable, but will occasionally be the best option for our patients."