In this episode, I’ll discuss a review article on the safety of peripheral vasopressors and hypertonic saline.
When advances in medical knowledge are accompanied by aggressive marketing campaigns, the use of new information in patient care can occur rapidly. However not all new data is accompanied by a marketing push, and while the translation of new knowledge to practice may not take 17 years on average as some have argued, it can often be delayed significantly.
While many institutions have recognized research that supports the use of peripheral vasopressors and hypertonic saline in certain patient populations, application of this data is not universal.
A group of authors recently published a review in the journal Pharmacotherapy that deals in part with summarizing the evidence regarding the safe peripheral administration of vasopressors and hypertonic saline.
The use of central venous catheters for IV delivery of vasopressors and hypertonic saline has traditionally been required under the assumption that central access is necessary to avoid patient harm due to tissue damage from extravasation or phlebitis due to hypertonic fluid administration. In the case of hypertonic saline, this requirement was simply inferred from adverse event data on parenteral nutrition.
But central venous catheters are not without their own serious risks including infection, thrombosis, and pneumothorax – all of which have the potential to be fatal.
In addition, when vasopressors or hypertonic saline infusions are indicated, there is often a time-sensitive reason for their use. Requiring the placement of a central venous catheter can significantly delay the administration of these other critical medications.
The authors of this review note that multiple systematic reviews and meta-analyses of observational and randomized controlled trials have found either no harm from peripheral administration of vasopressors or very low rates of severe reactions. The authors conclude that “the use of peripheral vasopressors is generally safe and may spare the need for a central venous catheter, particularly for shorter vasopressor durations.”
The authors of the review also thoroughly detail the evidence in support of using hypertonic saline via the peripheral route when time is of the essence both as a continuous infusion and as a bolus using even the 24.3% concentration solution.
In with both types of medication, the ideal catheter gauge size, anatomic location of the IV site, concentration of the infusion, and duration of therapy are unknown and there is still a preference for central venous access with high doses or prolonged infusion times.
If clinicians or administrators at your institution are hesitant to use peripheral access for these medications even when timely administration is required for hypotension or elevated intracaranial pressure related emergencies, this review article may provide the data and the argument needed to translate this research into practice.
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