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Observational Study
. 2024 Feb;165(2):348-355.
doi: 10.1016/j.chest.2023.08.019. Epub 2023 Aug 21.

Peripheral Administration of Norepinephrine: A Prospective Observational Study

Jason R Yerke  1 , Eduardo Mireles-Cabodevila  2 , Alyssa Y Chen  3 , Stephanie N Bass  3 , Anita J Reddy  2 , Seth R Bauer  3 , Lynne Kokoczka  4 , Siddharth Dugar  2 , Ajit Moghekar  2
Affiliations
Observational Study

Peripheral Administration of Norepinephrine: A Prospective Observational Study

Jason R Yerke et al. Chest. 2024 Feb.

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.

Keywords: catheter; hypotension; infusions; norepinephrine; parenteral; shock; vasoconstrictor agents.

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Conflict of interest statement

Financial/Nonfinancial Disclosures None declared.

Figures

None
Graphical abstract
Figure 1
Figure 1
Description of peripheral norepinephrine administration protocol. PIVC = peripheral intravenous catheter.
Figure 2
Figure 2
Graph showing time to extravasation in those experiencing an extravasation event.
See this image and copyright information in PMC

Comment in

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