Intravenous Vasoactive Medications Research Articles

Battling Hypotension in Cesarean Section

Perhaps the greatest day in a mother's life is the birth of her child. As a father of two, I will never forget those two drastically different, yet equally beautiful moments. In each circumstance, the obstetricians, nurses, anesthesia providers, and technicians all worked seamlessly to provide a safe and enjoyable childbirth experience for our new and growing family. One key element of the childbirth experience is maternal pain control. Depending on several factors, the parturient may receive an epidural, a spinal, a combined spinal/epidural, IV analgesics or perhaps nothing at all. One key commonality after any anesthetic administration is its propensity to cause hypotension, which is usually most profound after spinal anesthesia (SA). SA is the preferred method during elective cesarean sections due to the rapid and predictable onset and duration of action of local anesthetics injected directly into the cerebrospinal fluid. Immediately after SA is administered, the patient is helped to lay supine which assists the hyperbaric local anesthetic to move with gravity and rise cephalad from the lower lumber injection site (L3-L5) towards the desired T4 vertebra. While marching up those 12 dermatome levels, the local anesthetic quickly begins to attenuate sympathetic tone at every level along the way. Depending on the health of the patient's cardiovascular system, intravascular volume status and other factors, the sympathectomy and subsequent vasodilation can result in significant and symptomatic hypotension, causing a vast array of symptoms such as maternal nausea, vomiting, dizziness, and cardiovascular collapse as well as fetal acidosis and decreased Apgar scores. Preanesthesia fluid boluses are commonly administered in hopes to increase intravascular volume and lessen the severity of hypotension, but its effectiveness is unreliable. Acute arterial vasodilation is the primary cause of hypotension after SA. Intravenous vasoactive medications such as phenylephrine and ephedrine offer the fastest and most effective means of arterial vasoconstriction and subsequent correction of blood pressure; yet healthcare providers will always continue to search for alternative and less invasive methods of preventing and/or treating hypotension after SA.

Refractory Anaphylactic Shock Requiring Emergent Venoarterial Extracorporeal Membrane Oxygenation in the Emergency Department: A Case Report

Venoarterial extracorporeal membrane oxygenation is a viable salvage intervention for patients who experience cardiopulmonary arrest or profound shock from any cause. Acute anaphylactic shock is a rare cause of cardiac arrest. We present a case of a 35-year-old male who experienced cardiac arrest owing to anaphylactic shock while receiving general anesthesia for a routine outpatient surgical procedure. Traditional advanced cardiac life support therapies were provided by paramedics en route to the emergency department of a suburban, community-based hospital. Maximal medical management including endotracheal intubation, intravenous steroids, intravenous crystalloid fluid administration, intravenous vasoactive medications, and high-quality cardiopulmonary resuscitation was provided. Although return of spontaneous circulation was achieved, profound cardiogenic shock persisted. Venoarterial extracorporeal membrane oxygenation was initiated by the emergency department provider and nursing team. The patient survived, was neurologically intact, had full recovery, and was discharged home several days later. We have extensive experience with venoarterial extracorporeal membrane oxygenation, and this case exemplifies the value of an established emergency department extracorporeal membrane oxygenation program in managing all causes of cardiac arrest or refractory shock.

Treatment of Ebola-related critical illness.

PurposeTo explore contemporary clincial case management of patients with Ebola virus disease.MethodsA narrative review from a clinical perspective of clinical features, diagnostic tests, treatments and outcomes of patients with Ebola virus disease.ResultsSubstantial advances have been made in the care of patients with Ebola virus disease (EVD), precipitated by the unprecedented extent of the 2014–2016 outbreak. There has been improved point-of-care diagnostics, improved characterization of the clinical course of EVD, improved patient-optimized standards of care, evaluation of effective anti-Ebola therapies, administration of effective vaccines, and development of innovative Ebola treatment units. A better understanding of the Ebola virus disease clinical syndrome has led to the appreciation of a central role for critical care clinicians—over 50% of patients have life-threatening complications, including hypotension, severe electrolyte imbalance, acute kidney injury, metabolic acidosis and respiratory failure. Accordingly, patients often require critical care interventions such as monitoring of vital signs, intravenous fluid resuscitation, intravenous vasoactive medications, frequent diagnostic laboratory testing, renal replacement therapy, oxygen and occasionally mechanical ventilation.ConclusionWith advanced training and adherence to infection prevention and control practices, clinical interventions, including critical care, are feasible and safe to perform in critically ill patients. With specific anti-Ebola medications, most patients can survive Ebola virus infection.

P61 CARDIAC TAMPONADE - A SERIOUS COMPLICATION AFTER COLON CONDUIT INTERPOSITION: A CASE REPORT

Abstract Aim Graft redundancy and anastomotic stricture after colon interposition are well-known late complications. Cardiac compression by distended colon conduit is uncommon. There is a few reports in the literature. We present a case of 58-year-old patient with a major dilatation of colon conduit occurred 7 years after esophagectomy and gastrectomy. Case report The patient was admitted to district general hospital with 4-hour history of abdominal pain. Chest X- ray and abdominal computer tomography (CT) scan revealed distended colon conduit, pneumomediastinum, small-bowel ileus and pneumoretroperitoneum. An attempt to insert a nasogastric tube failed and an emergency laparotomy was performed. At operation, a band causing small bowel strangulation and adhesions were divided. The bowel appeared viable and a clear perforation was not found. Resection was not necessery. For next 10 hours, progressing hemodynamic instability and sepsis required intravenous vasoactive medication and orotracheal intubation. Chest CT scan showed massive distention of substernal colon conduit with compression of heart and pulmonary arteries. The patient was referred to our institution. Prompt endoscopy was performed with suction of air and liquid content from colon and nasogastric tube was inserted. The colonic mucosa was viable without necrosis and perforation. Hemodynamics improved immediately after decompression of colonic roll. An exploratory laparotomy revealed fatal extensive ischemia infarction of the bowel and the patient died within 4 hours after surgery. Concluson Extrapericardial cardiac tamponade is a rare complication after substernal esophageal reconstruction and could lead to bowel hypoperfusion or ischemia. Early recognition of symptoms and management with conduit decompression are important.

Demographics, Care Patterns, and Outcomes of Patients Admitted to Cardiac Intensive Care Units

Single-center and claims-based studies have described substantial changes in the landscape of care in the cardiac intensive care unit (CICU). Professional societies have recommended research to guide evidence-based CICU redesigns. To characterize patients admitted to contemporary, advanced CICUs. This study established the Critical Care Cardiology Trials Network (CCCTN), an investigator-initiated multicenter network of 16 advanced, tertiary CICUs in the United States and Canada. For 2 months in each CICU, data for consecutive admissions were submitted to the central data coordinating center (TIMI Study Group). The data were collected and analyzed between September 2017 and 2018. Demographics, diagnoses, management, and outcomes. Of 3049 participants, 1132 (37.1%) were women, 797 (31.4%) were individuals of color, and the median age was 65 years (25th and 75th percentiles, 55-75 years). Between September 2017 and September 2018, 3310 admissions were included, among which 2557 (77.3%) were for primary cardiac problems, 337 (10.2%) for postprocedural care, 253 (7.7%) for mixed general and cardiac problems, and 163 (4.9%) for overflow from general medical ICUs. When restricted to the initial 2 months of medical CICU admissions for each site, the primary analysis population included 3049 admissions with a high burden of noncardiovascular comorbidities. The top 2 CICU admission diagnoses were acute coronary syndrome (969 [31.8%]) and heart failure (567 [18.6%]); however, the proportion of acute coronary syndrome was highly variable across centers (15%-57%). The primary indications for CICU care included respiratory insufficiency (814 [26.7%]), shock (643 [21.1%]), unstable arrhythmia (521 [17.1%]), and cardiac arrest (265 [8.7%]). Advanced CICU therapies or monitoring were required for 1776 patients (58.2%), including intravenous vasoactive medications (1105 [36.2%]), invasive hemodynamic monitoring (938 [30.8%]), and mechanical ventilation (652 [21.4%]). The overall CICU mortality rate was 8.3% (95% CI, 7.3%-9.3%). The CICU indications that were associated with the highest mortality rates were cardiac arrest (101 [38.1%]), cardiogenic shock (140 [30.6%]), and the need for renal replacement therapy (51 [34.5%]). Notably, patients admitted solely for postprocedural observation or frequent monitoring had a mortality rate of 0.2% to 0.4%. In a contemporary network of tertiary care CICUs, respiratory failure and shock predominated indications for admission and carried a poor prognosis. While patterns of practice varied considerably between centers, a substantial, low-risk population was identified. Multicenter collaborative networks, such as the CCCTN, could be used to help redesign cardiac critical care and to test new therapeutic strategies.

Renin-angiotensin-aldosterone-system inhibition is safe in the preoperative period surrounding carotid endarterectomy

Discontinuation of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) medications before surgery has been suggested because of the potentially deleterious effects of hypotension. We investigated the effect of preoperative ACEI and/or ARB use on early outcomes after carotid endarterectomy (CEA). We examined 3752 consecutive CEA patients within the Vascular Study Group of New England from September 2012 to September 2014 and compared outcomes for patients treated (n = 1772) or not treated (n = 1980) with ACEI and/or ARB preoperatively. Outcomes included perioperative need for intravenous vasoactive medication (IVBPmed) for hypotension or hypertension (HTN), major adverse cardiac events (MACEs), and the combined outcome of stroke or death. Adjusted analysis was performed using multivariable logistic regression of the crude cohort and by constructing a propensity score matched cohort (n = 1441). ACEI and/or ARB users were more likely to be male (64% vs 59%; P = .001), with a higher prevalence of diabetes (41% vs 28%; P < .0001), HTN (97% vs 82%; P < .0001), coronary artery disease (31% vs 25%; P = .0001), congestive heart failure (10% vs 8%; P = .02), and asymptomatic carotid disease (59% vs 54%; P = .004). Patients who received ACEI and/or ARB preoperatively were more likely to be treated with aspirin (92% vs 88%; P = .0002) and statins (89% vs 85%; P = .001) preoperatively. In the unadjusted analysis, no significant differences were identified in hypotension that required IVBPmed (12% vs 11%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.9-1.4; P = .22), MACE (3% vs 2%; OR, 1.3; 95% CI, 0.8-1.9; P = .32), or stroke or death (3% vs 3%; OR, 1.0; 95% CI, 0.7-1.6; P = .89) for preoperative ACEI and/or ARB treated and nontreated patients, respectively. Preoperative ACEI and/or ARB usage was, however, associated with HTN that required IVBPmed (13% vs 10%; OR, 1.3; 95% CI, 1.1-1.6; P = .01). Analysis of the propensity score matched cohort revealed no significant differences in hypotension that required IVBPmed (12% vs 12%; OR, 1.0; 95% CI, 0.8-1.3; P = .86), MACE (3% vs 2%; OR, 1.1; 95% CI, 0.7-1.8; P = .62; ), or stroke or death (3% vs 3%; OR, 1.0; 95% CI, 0.7-1.6; P = .91) for patients treated or not treated with preoperative ACEI and/or ARB, respectively. ACEI and/or ARB remained associated with HTN that required IVBPmed (13% vs 10%; OR, 1.3; 95% CI, 1.0-1.7; P = .02). Results were similar after adjustment using logistic regression. The incidence of hospital length of stay >1 day was similar between ACEI and/or ARB treated and not treated patients (29% vs 32%; OR, 0.9; 95% CI, 0.8-1.1; P = .21). Preoperative ACEI and/or ARB use was associated with marginally increased use of IVBPmed for HTN but not for hypotension and was not associated with increased MACE, stroke, or death. On the basis of these metrics, the use of preoperative ACEI and/or ARB appears safe before CEA.

Safety of Oral Midodrine as a Method of Weaning From Intravenous Vasoactive Medication in the Medical Intensive Care Unit

Safety of Oral Midodrine as a Method of Weaning From Intravenous Vasoactive Medication in the Medical Intensive Care Unit

The need for treatment of hemodynamic instability following carotid endarterectomy is associated with increased perioperative and 1-year morbidity and mortality

The objective of this study was to evaluate the outcomes of patients after carotid endarterectomy (CEA) who developed postoperative hypertension or hypotension requiring the administration of intravenous vasoactive medication (IVMED). We examined consecutive, primary elective CEA performed by 128 surgeons within the Vascular Study Group of New England (VSGNE) database (2003-2010) and compared outcomes of patients who required postoperative IVMED to treat hyper- or hypotension with those who did not. Outcomes included perioperative death, stroke, myocardial infarction (MI), congestive heart failure (CHF), hospital length of stay, and 1-year stroke or death. Propensity score matching was performed to facilitate risk-adjusted comparisons. Multivariable regression models were used to compare the association between IVMED and outcomes in unmatched and matched samples. Factors associated with use of IVMED in postoperative hypertension and hypotension were evaluated, and predictive performance of multivariable models was examined using receiver operating characteristic (ROC) curves. Of 7677 elective CEAs identified, 23% received IVMED for treatment of either postoperative hypertension (11%) or hypotension (12%). Preoperative neurological symptomatic status (20%) was similar across cohorts. In the crude sample, the use of IVMED to treat postoperative hypertension was associated with increased 30-day mortality (0.7% vs 0.1%; P < .001), stroke (1.9% vs 1%; P = .018), MI (2.4% vs 0.5%; P < .001), and CHF (1.9% vs 0.5%; P < .001). The use of IVMED to treat postoperative hypotension was also associated with increased perioperative mortality (0.8% vs 0.1%; P < .001), stroke (3.2% vs 1.0%; P < .001), MI (2.7% vs 0.5%; P < .001), and CHF (1.7% vs 0.5%; P < .001), as well as 1-year death (5.1% vs 2.9%; P < .001) or stroke (4.2% vs 2.1%; P < .001). Hospital length of stay was significantly longer among patients who needed IVMED for postoperative hypertension (2.8 ± 4.7 days vs 1.7 ± 5.5 days; P < .001) and hypotension (2.8 ± 5.9 days vs 1.7 ± 5.5 days; P < .001). In multivariable analysis, IVMED for postoperative hypertension was associated with increased MI, stroke, or death (odds ratio, 2.6; 95% confidence interval [CI], 1.6-4.1; P < .001). Similarly, IVMED for postoperative hypotension was associated with increased MI, stroke, or death (odds ratio, 3.2; 95% CI, 2.1-5.0; P < .001), as well as increased 1-year stroke or death (hazard ratio, 1.6; 95% CI, 1.2-2.2; P = .003). Smoking, coronary artery disease, and clopidogrel (ROC, 0.59) were associated with postoperative hypertension requiring IVMED, whereas conventional endarterectomy and general anesthesia were associated with postoperative hypotension requiring IVMED (ROC, 0.58). The unitization of IVMED varied between 11% and 38% across VSGNE, and center effect did not affect outcomes. Postoperative hypertension requiring IVMED after CEA is associated with increased perioperative mortality, stroke, and cardiac complications, whereas significant postoperative hypotension is associated with increased perioperative mortality, cardiac, or stroke complications, as well as increased 1-year death or stroke following CEA. The utilization of IVMED varied across centers and, as such, further investigation into this practice needs to occur in order to improve outcomes of these at-risk patients.

Contemporary In-Hospital Management Strategies for Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is a common syndrome with diverse etiologies and precipitating factors, which is associated with significant morbidity and mortality. Tremendous resources are used in treating this syndrome, with few prospectively designed clinical trials to guide therapy. Patients suffering from ADHF are at increased risk for readmission to the hospital as well as an increased risk of death. Prompt identification and management of these patients can lead to shorter length of hospital stay, lower likelihood of readmission, and, perhaps, lower mortality. Initial treatment should target the relief of congestive symptoms. Intravenous loop diuretics are the mainstay of therapy, whereas ultrafiltration has emerged as a viable option in patients refractory to conventional treatment with diuretics. The safety and efficacy of nesiritide have been clarified in a recent large randomized trial, reassuring a favorable safety profile, but with modest improvement in short-term clinical outcomes. Thus, the preferred intravenous vasoactive medication has yet to be determined in large clinical trials, and positive inotropic agents should be reserved for patients with hemodynamic collapse. This article reviews the in-hospital assessment and management of ADHF.

Use and impact of inotropes and vasodilator therapy in hospitalized patients with severe heart failure

Treatment of decompensated heart failure often includes the use of intravenous vasoactive medications, but the effect on outcome has not been clearly defined. Data from 433 patients enrolled in the ESCAPE trial were analyzed to determine 6-month risks of all-cause mortality and all-cause mortality plus rehospitalization associated with the use of vasodilators, inotropes, and their combination. Patients had a mean left ventricular ejection fraction of 19%, 6-minute walk distance of 414 ft, and systolic blood pressure of 106 mm Hg. The main outcome measure was multivariable risk-adjusted 6-month hazard ratios (HRs). Overall 6-month mortality was 19%. Risk-adjusted HRs were not statistically significant for vasodilators (1.39, 95% CI 0.64-3.00), but were significant for inotropes (2.14, 95% CI 1.10-4.15) and the combination (4.81, 95% CI 2.34-9.90). Risk-adjusted 6-month mortality plus rehospitalization HRs were not significant for vasodilators (1.20, 95% CI 0.81-1.78, P = .37), but were significant for inotropes (1.96, 95% CI 1.37-2.82, P < .001) and their combination (2.90, 95% CI 1.88-4.48, P = .001). The decision to use vasodilators or inotropes was determined by hemodynamic parameters and renal function, but the main factor was treatment site. In ESCAPE, the choice of medications was mainly determined by the treatment site. Use of inotropic agents was associated with adverse outcomes, whereas the use of vasodilators was not. Inotropes in combination with vasodilators identified a group with the highest mortality. Prospective studies are needed to establish the appropriate use of vasoactive medications in this population.

In-Hospital Mortality in Patients With Acute Decompensated Heart Failure Requiring Intravenous Vasoactive Medications: An Analysis From the Acute Decompensated Heart Failure National Registry (ADHERE)

In-Hospital Mortality in Patients With Acute Decompensated Heart Failure Requiring Intravenous Vasoactive Medications: An Analysis From the Acute Decompensated Heart Failure National Registry (ADHERE)

In-Hospital Mortality in Patients With Acute Decompensated Heart Failure Requiring Intravenous Vasoactive Medications. An Analysis From the Acute Decompensated Heart Failure National Registry (ADHERE)

In-Hospital Mortality in Patients With Acute Decompensated Heart Failure Requiring Intravenous Vasoactive Medications. An Analysis From the Acute Decompensated Heart Failure National Registry (ADHERE)

In-Hospital Mortality in Patients With Acute Decompensated Heart Failure Requiring Intravenous Vasoactive Medications: An Analysis From the Acute Decompensated Heart Failure National Registry (ADHERE)

We sought to compare the in-hospital mortality of patients with acute decompensated heart failure (ADHF) who were receiving parenteral treatment with one of four intravenous vasoactive medications. There are limited data regarding the effects of the choice of intravenous vasoactive medication on in-hospital mortality in patients hospitalized with ADHF. This was a retrospective analysis of observational patient data from the Acute Decompensated Heart Failure National Registry (ADHERE), a multicenter registry designed to prospectively collect data on each episode of hospitalization for ADHF and its clinical outcomes. Data from the first 65,180 patient episodes (October 2001 to July 2003) were included in this analysis. Cases in which patients received nitroglycerin, nesiritide, milrinone, or dobutamine were identified and reviewed (n = 15,230). Risk factor and propensity score-adjusted odds ratios (ORs) for in-hospital mortality were calculated. Patients who received intravenous nitroglycerin or nesiritide had lower in-hospital mortality than those treated with dobutamine or milrinone. The risk factor and propensity score-adjusted ORs for nitroglycerin were 0.69 (95% confidence interval [CI] 0.53 to 0.89, p < or = 0.005) and 0.46 (94% CI 0.37 to 0.57, p < or = 0.005) compared with milrinone and dobutamine, respectively. The corresponding values for nesiritide compared with milrinone and dobutamine were 0.59 (95% CI 0.48 to 0.73, p < or = 0.005) and 0.47 (95% CI 0.39 to 0.56, p < or = 0.005), respectively. The adjusted OR for nesiritide compared with nitroglycerin was 0.94 (95% CI 0.77 to 1.16, p = 0.58). Therapy with either a natriuretic peptide or vasodilator was associated with significantly lower in-hospital mortality than positive inotropic therapy in patients hospitalized with ADHF. The risk of in-hospital mortality was similar for nesiritide and nitroglycerin.

256 Early use of nesiritide in the emergency department is associated with improved outcome: An ADHERE registry analysis

Study objectives: Most patients admitted for acute heart failure are first evaluated in the emergency department (ED). Previous analysis of data from the Acute Decompensated Heart Failure National Registry (ADHERE) showed that initiation of vasoactive therapy in the ED is associated with improved outcome compared with initiation of this therapy in the inpatient setting. This analysis compares ED versus inpatient initiation of nesiritide in acute heart failure. Methods: ADHERE contains data from 265 acute care hospitals and includes community and academic institutions. We analyzed data from patients whose initial point of care was the ED, who were then admitted for acute heart failure from October 2001 through July 2003, and who received intravenous nesiritide in the ED or after hospitalization but did not receive other intravenous vasoactive medications. Differences were compared between patients who first received nesiritide in the ED (n=803) and those whose nesiritide therapy began after admission (n=1,223) by using analysis of variance, Wilcoxon, and χ2 tests along with risk adjustment models for clinical, historical, and laboratory findings known to affect outcome. Results: Median time to initiation of nesiritide in the ED (ED initiation) was 2.7 hours compared with 18.3 hours when treatment was initiated after admission (inpatient initiation; P<.0001). Median hospital length of stay was 4.1 days with ED initiation versus 5.7 days with inpatient initiation (P<.0001). A larger percentage of patients who had inpatient initiation of nesiritide required transfer to the ICU and had prolonged length of stay (highest quartile) compared with patients who had ED initiation (9% versus 2% and 35% versus 19%, respectively; P<.0001). On a risk-adjusted basis, delay of administration of nesiritide until after admission (compared with ED initiation) meant that patients were more than 2 times as likely to have prolonged length of stay. Conclusion: Early ED intervention with nesiritide yields better outcomes compared with later inpatient initiation of nesiritide treatment. These data corroborate the growing evidence that ED management of heart failure affects outcomes and underscores the need for an aggressive, timely approach to managing acute heart failure in the ED. Study objectives: Most patients admitted for acute heart failure are first evaluated in the emergency department (ED). Previous analysis of data from the Acute Decompensated Heart Failure National Registry (ADHERE) showed that initiation of vasoactive therapy in the ED is associated with improved outcome compared with initiation of this therapy in the inpatient setting. This analysis compares ED versus inpatient initiation of nesiritide in acute heart failure. Methods: ADHERE contains data from 265 acute care hospitals and includes community and academic institutions. We analyzed data from patients whose initial point of care was the ED, who were then admitted for acute heart failure from October 2001 through July 2003, and who received intravenous nesiritide in the ED or after hospitalization but did not receive other intravenous vasoactive medications. Differences were compared between patients who first received nesiritide in the ED (n=803) and those whose nesiritide therapy began after admission (n=1,223) by using analysis of variance, Wilcoxon, and χ2 tests along with risk adjustment models for clinical, historical, and laboratory findings known to affect outcome. Results: Median time to initiation of nesiritide in the ED (ED initiation) was 2.7 hours compared with 18.3 hours when treatment was initiated after admission (inpatient initiation; P<.0001). Median hospital length of stay was 4.1 days with ED initiation versus 5.7 days with inpatient initiation (P<.0001). A larger percentage of patients who had inpatient initiation of nesiritide required transfer to the ICU and had prolonged length of stay (highest quartile) compared with patients who had ED initiation (9% versus 2% and 35% versus 19%, respectively; P<.0001). On a risk-adjusted basis, delay of administration of nesiritide until after admission (compared with ED initiation) meant that patients were more than 2 times as likely to have prolonged length of stay. Conclusion: Early ED intervention with nesiritide yields better outcomes compared with later inpatient initiation of nesiritide treatment. These data corroborate the growing evidence that ED management of heart failure affects outcomes and underscores the need for an aggressive, timely approach to managing acute heart failure in the ED.

Practical considerations in the administration of intravenous vasoactive drugs in the critical care setting: the double pumping or piggyback technique?part one

Part I of this review aims to identify the factors associated with safe administration of continuous intravenous vasoactive drug therapy, specifically epinephrine and norepinephrine. Intravenous vasoactive drugs are administered in the critical care setting to maintain patients’ cardiovascular function by continuous intravenous infusion. To ensure uninterrupted administration, one infusion is commenced when the other is almost empty. A technique often employed to achieve this is known as ‘double pumping’ or ‘piggybacking’. Due to the absence of a standardised protocol for administering continuous intravenous vasoactive medication and technological developments in infusion pumps, a review of current literature was undertaken. Despite a paucity of evidence regarding safe administration of these drugs, recommendations from the available literature included ensuring that critical care nurses are competent and formally trained in the use of equipment and the administration of continuous intravenous vasoactive medication. Furthermore, the infusion pump should feature minimal start up delay, a sensitive occlusion alarm system and the absence of a bolus in the event of infusion occlusion. This may reduce patients experiencing adverse haemodynamic responses due to alterations to the infusion. Indeed, a review of the ‘double pumping’ or ‘piggybacking’ technique in the clinical setting is required to establish current practice and develop evidence based guidelines.

Practical considerations in the administration of intravenous vasoactive drugs in the critical care setting: the double pumping or piggyback technique-part one.

Part I of this review aims to identify the factors associated with safe administration of continuous intravenous vasoactive drug therapy, specifically epinephrine and norepinephrine. Intravenous vasoactive drugs are administered in the critical care setting to maintain patients' cardiovascular function by continuous intravenous infusion. To ensure uninterrupted administration, one infusion is commenced when the other is almost empty. A technique often employed to achieve this is known as 'double pumping' or 'piggybacking'. Due to the absence of a standardised protocol for administering continuous intravenous vasoactive medication and technological developments in infusion pumps, a review of current literature was undertaken. Despite a paucity of evidence regarding safe administration of these drugs, recommendations from the available literature included ensuring that critical care nurses are competent and formally trained in the use of equipment and the administration of continuous intravenous vasoactive medication. Furthermore, the infusion pump should feature minimal start up delay, a sensitive occlusion alarm system and the absence of a bolus in the event of infusion occlusion. This may reduce patients experiencing adverse haemodynamic responses due to alterations to the infusion. Indeed, a review of the 'double pumping' or 'piggybacking' technique in the clinical setting is required to establish current practice and develop evidence based guidelines.