pressors without central access

[Boatswain2PA]

What are the best options if you need to run pressors but you are in a very remote hospital. It takes 4-5 hours to get patients to tertiary center from this area, sometimes more depending on weather.

What most docs here are currently doing is just running them peripherally (and still using dopamine).

What would you do in this setting? Phenylephrine as first choice due to less risk of necrosis with extravasation? Would IO be better for norepi? What about an EJ??

Would love to hear your thoughts on this, thank you in advance.

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[exsanguination]

I don't understand. The remote-ness means you can't get central access?

I would avoid EJ simply because tissue necrosis here would be worse then practically anywhere. However I would still run norepi peripherally if I had a great fat line in an AC. But come on, put in a IJ or subclavian or something. The remote location and long transfer time argues even more for stable central access.

This was exactly my thinking when I read the question. What's preventing the hypothetical EP in this scenario from getting central access?

 

[WilcoWorld]

The OP is a PA. Perhaps he/she is not privileged to put in CVLs and could be fired for doing so, even if it was the silkiest line ever placed.

 

[WilcoWorld]

In my post above "slickest" was autocorrected to "silkiest", but I like that so much I've decided to leave it as is.

 

[exsanguination]

The OP is a PA. Perhaps he/she is not privileged to put in CVLs and could be fired for doing so, even if it was the silkiest line ever placed.

TOTALLY didn't see it was boatswain who made the OP... based on his/her previous posts it appears that they work in a fairly rural environment where they've probably done more procedures than many urban EPs. But even then, if your shop is allowing PAs to place patients on pressors but for some reason they're not allowed to place lines then your SOP needs to be re-evaluated.

Point still stands though for the original question, why not just place a CVL?

But if for some reason you've burned through your last kit or whatever, I'd stick with a good AC line, 18g or greater. I think IOs are just as dangerous as hand/wrist IVs for extravasation. Think about it... how many times have you placed an IO that seemed like it flushed and worked well only to find 5-10 minutes later that compartment has started to swell. Granted, it's not COMMON, but it's frequent enough for me to not use IOs for anything other than initial resus prior to getting a CVL/larger peripheral.

Emcrit had a good podcast on this one along with tips for what to do when it happens (hint: subcutaneous phentolamine and pushing a little through the bunk line prior to d/c'ing it). http://emcrit.org/podcasts/peripheral-vasopressors-extravasation/

 

[mdmacros]

There is some trend towards peripheral IV as the sole method of administration of pressors:

http://pulmccm.org/main/2015/critic...ines-really-needed-for-vasopressor-infusions/

And the article in question:
http://onlinelibrary.wiley.com/doi/...ionid=9EC749E7971F5F85A30AB4DEAAA72D78.f01t01

Granted it is a limited study (single center, expert ultrasonographers that teach the US courses at the big conferences) but it is food for thought.

 

[xaelia]

Not very worried about extravasation and tissue injury.

Think about an epipen – that's 300 micrograms in 0.3 mL. They've published studies of accidental epipen injection into the hand/fingers, and nothing died. Your typical norepinephrine drip is something like 32 micrograms per mL, with rates typically in the 2-20 micrograms per minute. I can't imagine an arm rotting or serious damage associated with tissue extravasation from our typical peripheral pressors excepting situations of most extreme neglect.

So, yes, anyways, I'd have no issue running norepinephrine peripherally through a solid IV, and if there are any access concerns, IOs are well-tolerated and safe.

 

[exsanguination]

Not very worried about extravasation and tissue injury.

Think about an epipen – that's 300 micrograms in 0.3 mL. They've published studies of accidental epipen injection into the hand/fingers, and nothing died. Your typical norepinephrine drip is something like 32 micrograms per mL, with rates typically in the 2-20 micrograms per minute. I can't imagine an arm rotting or serious damage associated with tissue extravasation from our typical peripheral pressors excepting situations of most extreme neglect.

So, yes, anyways, I'd have no issue running norepinephrine peripherally through a solid IV, and if there are any access concerns, IOs are well-tolerated and safe.

I've thought about epipen dosing/administration example too, and I think there are a few things that make it slightly different. I'll warn you though, this is all theoretical and what I've come up with for reasons to be worried about NE extrav vs. epinephrine. But I will say that I've definitely seen tissue necrosis with NE extravasation in the ICU, though only once and it definitely wasn't a case of extreme neglect.

NE is a more potent alpha 1 agonist than epinephrine, thus less dosing required for similar amounts of vasoconstriction. I've also read that NE is much better at constricting the venule beds compared to similar doses of epinephrine (probably for similar receptor avidity reasons). Lastly, the beta-2s that line the endothelium (which have some vasodilatory effect) confer SOME protection against epinephrine's alpha activity, though as we all remember from medical school, the overall action of NE on the vessels is vasoconstriction.

Just my thoughts on the matter... no real studies to back this one up

 

[diphenyl]

Good summation from da' man Weingart aka Doc Hollywood

 

[Janders]

I am very comfortable using peripheral levophed (norepi, or NorAd my personal fav), preferably through a tested good flowing 18g, at least for the 1-2 hours I need to stabilize someone and place a CVL when I am solo-coverage.

I also don't mind doing it for longer if the patient doesn't want a CVL but does want pressors, in the "you can have it your way!" world of advanced directives.. documenting rationale of course.

In the situation you describe, I would personally place a CVL prior to shipping them 5 hours. If CVL unavailable due to local talent, I personally don't think I/O is any safer than a well-flowing PIV, in that I've certainly seen a few of them leak locally a couple hours into use. I would use a good flowing PIV, and not an EJ if I could get one in the arm. As far as pressor selection, I agree phenylephrine sounds potentially safer but its going to be hard to find evidence for that.

SPEAKING OF EVIDENCE, Weingart of course has a lovely podcast and wed page review of this topic-- apparently a lot of ICUs are getting away with PIV pressors using a protocolized approach to safety-- http://emcrit.org/podcasts/peripheral-vasopressors-extravasation/#ITEM-5074-1

If placing CVLs isn't going to happen at your shop, I'd put heads together with the EMS transfer teams and comeup with a written protocol everyone feels safe with, and then use it to protect you and your patients.

 

[Janders]

DAMNIT, I got beat to the weingart linkage!!!

 

[link2swim06]

What are the best options if you need to run pressors but you are in a very remote hospital. It takes 4-5 hours to get patients to tertiary center from this area, sometimes more depending on weather.

What most docs here are currently doing is just running them peripherally (and still using dopamine).

What would you do in this setting? Phenylephrine as first choice due to less risk of necrosis with extravasation? Would IO be better for norepi? What about an EJ??

Would love to hear your thoughts on this, thank you in advance.

But why do you guys run dopamine? Esp if these are sepsis patients....

Use levophed.

 

[Boatswain2PA]

TOTALLY didn't see it was boatswain who made the OP... based on his/her previous posts it appears that they work in a fairly rural environment where they've probably done more procedures than many urban EPs. But even then, if your shop is allowing PAs to place patients on pressors but for some reason they're not allowed to place lines then your SOP needs to be re-evaluated.

Point still stands though for the original question, why not just place a CVL?

But if for some reason you've burned through your last kit or whatever, I'd stick with a good AC line, 18g or greater. I think IOs are just as dangerous as hand/wrist IVs for extravasation. Think about it... how many times have you placed an IO that seemed like it flushed and worked well only to find 5-10 minutes later that compartment has started to swell. Granted, it's not COMMON, but it's frequent enough for me to not use IOs for anything other than initial resus prior to getting a CVL/larger peripheral.

Emcrit had a good podcast on this one along with tips for what to do when it happens (hint: subcutaneous phentolamine and pushing a little through the bunk line prior to d/c'ing it). http://emcrit.org/podcasts/peripheral-vasopressors-extravasation/

Yes, a PA. I work several different places, mostly ranging from rural to very very rural, although I do pull a couple shifts a month at a level II with about 35K visits a year. I do that job strictly for the privilege of working (and therefore learning from) BC EPs.

As for procedures...some days yes, some days no. On the "yes" days I wish I had more training (again, that's why I pull shifts at the level II center) doing them. Had an absolute nightmare airway today, and then reset a bad trimalleolar ankle. Both went well, but...whew! But I'm not proficient at CVLs, and many places I work don't even have them.

I've watched this from Weingart (along with every other one of his podcasts....his acid/base podcasts make me brain hurt) but, as you can tell from these responses, there is still a lot of controversy about peripheral pressors.

But why do you guys run dopamine? Esp if these are sepsis patients....

Use levophed.

I don't use dopamine. I use levophed, then vasopressin as secondary. Tank, pipes, pump.

Huge thanks to everyone for sharing their experience and knowledge.

 

[Druggernaut]

But why do you guys run dopamine? Esp if these are sepsis patients....

Use levophed.

I've heard of people preferring dopamine over Levophed when they have to give a peripheral pressor due to the belief that there will be less tissue necrosis if the dopamine extravasates versus if Levophed did. No idea if there's any evidence to support that, but it is a belief that some people hold.

Some of the rural hospitals our upper level residents moonlight at also don't have easy access to Levophed, but dopamine is premixed. If a pharmacist was available, they could have them mix up the Levophed, but apparently the nurses don't know how to do it, so you make do with what you have.

 

[diphenyl]

DAMNIT, I got beat to the weingart linkage!!!

Had to do it lol. Saw him at ACEP this year. This particular topic is probably the one I most associate with him since he's put out so many very agressive stances about it online.

 

[tkim]

Had to do it lol. Saw him at ACEP this year. This particular topic is probably the one I most associate with him since he's put out so many very agressive stances about it online.

Saw him at ACEP as well. Angry man. Me like.

 

[b-real]

I just still don't understand why you can't get central access. Sure, maybe you start peripheral pressers. But are you not actively getting central access to switch it over? It should be running for a matter of minutes, not hours, and certainly not during a transfer.

Dude's a PA and isn't credentialed for central access.

 

[Boatswain2PA]

I just still don't understand why you can't get central access. Sure, maybe you start peripheral pressers. But are you not actively getting central access to switch it over? It should be running for a matter of minutes, not hours, and certainly not during a transfer.

Some places I work don't have them in the building. As in NOBODY does CVLs there, so they don't stock them.

While most doc's work at big urban hospitals that have every resource known to man, most hospitals are community hospitals which often have a single provider and very limited specialty care. Please remember that when you are an attending and some rural doc/PA/NP is calling you to transfer a patient. Several times I've had to paint the picture of how small and remote, and how limited our resources are, to a physician at a tertiary center so they would accept transfer.

Dude's a PA and isn't credentialed for central access.

PA? Yes

Credentialed to do central lines? Yes at some shops, no at others

Proficient at doing central lines? No, which requires me to be very slow, very precise, and very very careful.

 

[tkim]

Methylene blue for sepsis

 

[goodoldalky]

Some places I work don't have them in the building. As in NOBODY does CVLs there, so they don't stock them.

Would you practice at a hospital without a pulse ox? There are some cases when CVLs can be critically important. I can't imagine any hospital / ED not having them. If that is the case that is a serious failure on the part of the medical director, I don't care how uncommonly they are needed.

As for the primary question there's really no benefit to using dopamine peripherally as opposed to norepinephrine, and since dopamine is inferior generally speaking in sepsis I would start peripheral norepi in these situations.

 

[b-real]

Some places I work don't have them in the building. As in NOBODY does CVLs there, so they don't stock them.

While most doc's work at big urban hospitals that have every resource known to man, most hospitals are community hospitals which often have a single provider and very limited specialty care. Please remember that when you are an attending and some rural doc/PA/NP is calling you to transfer a patient. Several times I've had to paint the picture of how small and remote, and how limited our resources are, to a physician at a tertiary center so they would accept transfer.



PA? Yes

Credentialed to do central lines? Yes at some shops, no at others

Proficient at doing central lines? No, which requires me to be very slow, very precise, and very very careful.

Then get more practice at the places you are credentialed. With experience you should be able to place an US-guided IJ within a few minutes.

 

[Boatswain2PA]

Then get more practice at the places you are credentialed. With experience you should be able to place an US-guided IJ within a few minutes.

Working on it....

Again, greatly appreciate everyone who shared their knowledge & experience here.

 

[shookwell]

I think the evidence for peripheral pressors is promising, but I want a little more before changing my practice completely. It's enough to make me start pressors peripherally, and sometimes not place a central line if they may come off the pressors in a reasonable time frame, but I'm still placing a CVL for patients who will probably need pressors for a while.

I think I'm a little biased toward placing lines since I have residents who are eager to do them, and most of the time I have a senior resident who can walk the junior through the line with very little involvement/effort from me. I find myself placing less lines when I work at the side gig where there are no residents and deciding to place a line means I'm going to fall behind for a bit. This makes me think that I should probably place less lines, even though the residents don't like that.

I do virtually all lines ultrasound guided (including subclavian) except with coding/dying patients where I make the residents place blind subclavian or supraclaviculars so that they have that skill.

 

[deleted109597]

Then get more practice at the places you are credentialed. With experience you should be able to place an US-guided IJ within a few minutes.

If there were US machines at that shop, which still isn't SOP in 2016 in many places. $60K machines don't fall out of the sky, you know. You have a tough sell to critical access hospitals barely keeping their doors open that a machine used 1x per week or month is worth the expense. Especially if 1% of the docs there know how to use it. Or do you mean grabbing the one out of radiology? Yeah, no politics there.

Would you practice at a hospital without a pulse ox? There are some cases when CVLs can be critically important. I can't imagine any hospital / ED not having them. If that is the case that is a serious failure on the part of the medical director, I don't care how uncommonly they are needed.
As for the primary question there's really no benefit to using dopamine peripherally as opposed to norepinephrine, and since dopamine is inferior generally speaking in sepsis I would start peripheral norepi in these situations.

Eh, IOs are better and easier than CVLs. I'm sure there are places that it would be much easier to get IO buy in than CVL buy in. I mean, look at the EMS world. Who puts in central lines prehospital?

 

[b-real]

If there were US machines at that shop, which still isn't SOP in 2016 in many places. $60K machines don't fall out of the sky, you know. You have a tough sell to critical access hospitals barely keeping their doors open that a machine used 1x per week or month is worth the expense. Especially if 1% of the docs there know how to use it. Or do you mean grabbing the one out of radiology? Yeah, no politics there.

Eh, IOs are better and easier than CVLs. I'm sure there are places that it would be much easier to get IO buy in than CVL buy in. I mean, look at the EMS world. Who puts in central lines prehospital?

The top of the line machines cost 60k, not some minging sonosite that gives you a view of the vessels. This is 2016, and US-guided lines are approaching standard of care. The ppl who never trained on US need to, asap. While peripheral and IO lines can be used to run pressors, I haven't seen data saying they can be used indefinitely. A corollary is that If you can't do the job of an EP, you shouldn't be the sole provider.

 

[engineeredout]

I will use push dose pressors or temporarily run a pressor gtt through a PIV as I'm simultaneously getting central access in a crashing patient. Would I trust a longstanding gtt to a PIV? Not likely. Why? I've seen FAR too many peripheral IVs, including long ones I've put in large veins under ultrasound guidance and walked them in to ensure there are centimeters of catheter in the vessels magically "fall out" at any given time. Patients move, and their IVs come out. Patients are disoriented, either due to illness or intoxication, and IVs come out. Patients get moved into different beds, get turned for cleaning, get their clothes changed, and IVs come out. I don't plan on sitting at the patients bedside monitoring the IV to ensure it is still in place, and I don't plan on taking the liability for the damage that can occur if someone's arm now contains more pressor that a code cart.

 

[gman33]

I hope that someday soon running pressors via a PIV becomes the default practice.

I work in a community hospital.
If the person needs a central line, it is going to be placed by me.
Placing a nice, sterile line takes some time.
I like doing the procedure, but it takes some time to do it correctly.

Time is my most valuable asset at work.

There are plenty of patients who would be better off getting early pressors rather than 4 L of fluid.

The situation I hate most is being asked to place a CVC by the admitting team just in case someday needs pressors someday.

There are cases where a CVC is needed emergently and I'm glad to place it in those situations.
I just don't think they are needed as often as people think.

I'm pretty good at u/s lines.
That's my go to for anyone just needing access, and it's exceedingly rare when I can't find something good in a couple of minutes.

 

[Old Grunt]

I just still don't understand why you can't get central access. Sure, maybe you start peripheral pressers. But are you not actively getting central access to switch it over? It should be running for a matter of minutes, not hours, and certainly not during a transfer.

Yeah, don't know about you, but once I left the sunny halls of academia and worked in some rural EDs with six beds and only you and two nurses in the entire hospital overnight and no working ventilators and found myself with a patient that was sick as snot and needed to get quickly stabilized and thrown in an ambulance, I was really surprised how quickly I broke almost all of those hard and fast rules I learned in residency.

OP: I've run levophed through a peripheral line, both in trying to press them a little bit while getting a CVC and also when I didn't try a CVC. It's probably not optimal and I try not to do it, but to date none of my patient's heads have exploded.

At least not from that.

 

[deleted109597]

The top of the line machines cost 60k, not some minging sonosite that gives you a view of the vessels. This is 2016, and US-guided lines are approaching standard of care. The ppl who never trained on US need to, asap. While peripheral and IO lines can be used to run pressors, I haven't seen data saying they can be used indefinitely. A corollary is that If you can't do the job of an EP, you shouldn't be the sole provider.

There's this place called reality. You should go there sometime.
Just like VL will never become standard of care everywhere, US guided CVLs also won't. It's a matter of economics. Sure, there's times I wish I had one, but I simply don't at every hospital. Hell, I don't have one in my pediatric trauma center teaching hospital. Wishes don't make things happen.

 

[daveyjwin]

I can't help but wonder, is a complication from a central line more or less likely than a complication from peripheral pressor use?

 

[cbrons]

Are central lines really needed for vasopressor infusions?

Edit - oops someone got it before me.