Peripheral Intravenous Line Research Articles

IV Ciprofloxacin-Induced Phlebitis: Investigating the Impact of Pharmaceutical and Process-Related Factors on Patient Safety

Transient phlebitis is a rare but notable adverse reaction that can occur following intravenous administration of various medications, including ciprofloxacin, an antibiotic recognized for its broad-spectrum activity. This case report discusses a 48-year-old male patient with poorly controlled type 2 diabetes who developed phlebitis after receiving undiluted ciprofloxacin via a peripheral intravenous line. Symptoms emerged within 24 hours, characterized by swelling and redness at the injection site, prompting the discontinuation of the medication. Analysis revealed that improper dilution and rapid infusion rate were major factors contributing to the development of phlebitis. This underscores the importance of adhering to guidelines provided in product information leaflets for intravenous drug preparation and administration. The case emphasizes the critical need for healthcare professionals to follow recommended protocols to reduce the risk of infusion-related complications, especially in patients with underlying comorbidities.

Extravasation with methylthioninium chloride

Introduction Methylthioninium chloride is used for multiple treatment purposes and is sometimes administered through peripheral intravenous lines. We highlight the potential adverse effects of methylthioninium chloride extravasation during continuous peripheral intravenous administration. Case summary A 38-year-old woman presented to the emergency department with multifactorial hypovolemic and septic shock. She was treated with a continuous peripheral infusion of intravenous methylthioninium chloride for shock refractory to multiple vasopressors. Images One day after administration commenced, the patient developed blue staining of the left upper arm due to extravasation of methylthioninium chloride proximal to the site of infusion. Further images show its later spread. Conclusion While reported cases of methylthioninium chloride extravasation are rare, it is our preference that methylthioninium chloride should be administered through a central line in cases of continuous infusion due to the risk of potential toxicity from extravasation.

Catheters linked thrombosis in neonates: a single center observational study

BackgroundCentral venous catheters (CVCs) are the major risk factors for neonatal thrombosis that might negatively affect morbidity and mortality in neonates. The aim of the present work was to estimate the incidence of CVC-linked thrombosis, among neonates in the NICU of Alexandria University Maternity Hospital, Egypt, over 1year, and to determine its possible risk factors.MethodsThis observational cohort study involved 134 newborn infants born from July 2020 to July 2021with CVCs insertion during their hospital stay. Patients who had congenital anomalies, had thrombosis unrelated to the implantation of CVCs or died before 7 days of catheter placement were excluded from the analysis. The 134 neonates who met the study’s eligibility requirements had 142 CVCs inserted. Serial ultrasound and Doppler scans on site of venous insertion of catheters were performed.ResultsSeventeen patients with catheter’s thrombosis (12%) were found during the placement of 142 catheters or 1615 CVCs’ days, resulting in an overall rate of 10.5 thrombotic events per 1000 catheters’ days. We constructed a logistic regression model to identify risk factors behind CVC-linked thrombosis. In univariate analysis, femoral central venous lines (CVLs), catheter dwell-time, sepsis, packed red cells (PRBCs) transfusions and low platelet count were risk factors for CVC-linked thrombosis. Nevertheless, only PRBCs transfusion was significant in the multivariate analysis, with OR and 95% confidence level 5.768 (1.013–32.836).ConclusionMany factors should be considered in prediction of patients at risk of thrombosis including sepsis, femoral line insertion, low platelet count and PRBCs-transfusions. In our analysis, PRBCs-transfusion through peripheral intravenous lines (PIVs) was the strongest factor associated with CVC-linked thrombosis.

Knowledge, Attitude, and Practices Toward Kangaroo Mother Care Among Mothers in a Tertiary Neonatal Care Unit

Aim: To study the knowledge, attitude, and practices of Kangaroo Mother Care (KMC) among eligible postnatal mothers in the postnatal ward (PNW) and neonatal intensive care unit (NICU) of a tertiary neonatal unit in Eastern India. Methods: A cross-sectional survey was conducted among 100 mothers of low-birth-weight babies in our PNW and NICU. As part of the unit protocol, all mothers of eligible babies were counseled about KMC at first contact verbally as well as by using an informative video on KMC. Data was collected using a structured questionnaire after the routine counseling of the mothers on their first visit after delivery. The analysis of the data was done using appropriate statistics. Results: More than three-fourths (83.2%) of mothers had good knowledge of KMC. A good attitude toward using KMC was found in 91.6% of the mothers. Almost all the mothers (98%) knew the correct KMC position, and 12% of mothers had a previous preterm baby and had given KMC. Many mothers felt the small size of the baby, pain after cesarean section, and central or peripheral intravenous lines in the baby were barriers to KMC. Conclusion: The knowledge regarding KMC among mothers whose babies were admitted into the PNW/NICU was good. Though the attitude toward KMC was good, mothers felt there were multiple barriers to initiating KMC.

Impact of a Vascular Access Specialty Service on Hospitalized Pediatric Patients: A Pilot Feasibility Study

Highlights Our project implementing a VAST produced these improved outcomes. There were 31% fewer IV devices. There were 22% fewer needle sticks. There were 49% reduction in delays. Abstract Background: Vascular access is essential in the care of hospitalized pediatric patients. Planning and device selection are important for optimal patient outcomes. Vessel preservation is critical for pediatric patients. Purpose: To determine and evaluate the impact of a vascular access team on pediatric patient care. Methods: A vascular access specialist team (VAST) was implemented on one medical unit at a tertiary children’s hospital, 16 hours a day for 4 weeks. Data Analysis: Descriptive statistics were used, including (a) first-stick success rates, (b) number of needle sticks and vascular access devices per hospital stay, (c) delays in therapy, and (d) frequency of topical analgesic use. Preintervention data were compared with postintervention data. Qualitatively, nursing and medical staff were surveyed to evaluate their perception of project experiences. Results: Compared with preintervention data, 56% fewer peripheral intravenous lines were initiated, and 31% fewer total vascular access devices were used during the hospital stay. There were 22% fewer needle sticks per peripheral intravenous line attempt. The first-stick success rate of the VAST was 71% compared with the bedside nurse rate of 52%. There was a 78% reduction in time between devices/1000 patient-days/week, representing reduced interruptions in therapy. The use of topical anesthetics for intravenous device placement increased 333%. Conclusion: This project provided clarity regarding the value of the VAST for pediatric hospitalized patients. The VAST model is evidence based, follows best-practice guidelines, is fiscally sound, and optimizes nursing practice and quality patient care.

The practice of umbilical vessels catheterization in neonatal intensive care units: a survey

Background: Umbilical venous catheterization and umbilical arterial catheterization provides easy access for administering fluids, exchange transfusion, medications, parenteral nutrition, blood pressure monitoring and blood sampling in neonates. Objective was to know the common practices related to the placement and maintenance of umbilical catheters, along with the associated complications in the level 3 and 4 neonatal intensive care units in the USA. Methods: A questionnaire-based survey study was conducted among NICU practitioners across United States. Only one survey was sent to each NICU. Results: Among the survey respondents, 50.8% represented level 3 NICUs, while 49.2% represented level 4 NICUs. The maximum duration for both UVC and UAC use was commonly reported as up to 7 days. Birth weight was the predominant method (86.8%) used for calculating catheter length. X-rays were universally employed for position confirmation. Heparin was widely utilized through UVC (96.7%), with a concentration of 0.5 IU/ml (73.7%). In cases of malpositioned UVC, practitioners employed techniques such as inserting another catheter, utilizing twisting movements during insertion, adjusting the UVC to a low position, and replacing the malpositioned UVC with a peripheral intravenous line. Common complications associated with UVC included line occlusion, thrombosis, and infections, while poor extremity perfusion and thrombosis were reported with UAC. Most units allowed feeding even when patients had a UAC in place. Conclusions: Despite the presence of institutional policies in most NICUs, practitioners encountered several complications during the use of umbilical catheters.

Comparing contamination rates of sterile-covered and uncovered transducers for ultrasound-guided peripheral intravenous lines

IntroductionPhysicians frequently use point-of-care ultrasound for intravenous access and bloodwork in the ED. Recently, AIUM and ACEP released recommendations on ultrasound-guided peripheral intravenous lines (USPIVs), but there are no agreed upon standardized policies. We sought to determine whether the use of sterile-covered transducers (SCT) decreases the rate of contamination when compared to uncovered transducers (UCT) after standard low-level disinfection (LLD).MethodsThis is a randomized control trial comparing contamination rates of US transducers between SCT and UCT after their use for USPIV by the vascular access team, also known as the “PICC” team, over a 3-month period. A sample of admitted patient with an USPIV order were included and randomized to SCT (experimental) or UCT (control) arms. Transducers were swabbed and inserted into the SystemSURE Plus Adenosine Triphosphate (ATP) Luminometer to calculate Relative Light Units (RLU). We performed a cost analysis of requiring sterile covers for USPIVs.ResultsThe UCT and SCT arms contained 35 and 38 patients, respectively. The SCT group had a mean of 0.34 compared to the UCT group mean of 2.29. Each sterile cover costs $8.49, and over 3000 USPIVs are placed annually by the “PICC” team.ConclusionContamination rates were similar among the UCT and SCT groups after LLD. 254 inpatient USPIVs are performed monthly, not including failed attempts or covers used in the ED where USPIV placement is an essential part of ED workflow. This study suggests that the use of SCT does not significantly affect transducer contamination rates. These findings question burdensome regulatory hospital policies that are not evidence-based.

Decreasing Pain in Hospitalized Patients by Increasing Topical Anesthetic Use for Peripheral IVs.

Venous access is a common source of pain for hospitalized patients. Topical anesthetics are effective at decreasing needle pain, can improve success rate, and decrease procedure time; however, use before peripheral intravenous line (PIV) placement is inconsistent. The aim was to reduce pain experienced by hospitalized pediatric patients by increasing topical anesthetic use for PIV placement from a mean of 11% to 40% within 6 months. The Model for Improvement was utilized. An institutional clinical pathway and PIV order panel were developed. Pre-checked orders for topical anesthetics were added to order sets. Visual aids were placed on IV carts, including reminders for anesthetics, pathway use and scripting examples. Nurses received individual feedback. Statistical process control charts were posted weekly on daily management system boards on medical-surgical floors, and data were shared at daily nursing huddles to increase awareness of performance and discuss opportunities for improvement. Topical anesthetic use for PIV placement increased from a mean of 11% to 46%. Documentation of comfort measures during PIV placement increased from a mean of 6% to 13%. The percentage of PIV placements with an order for a topical anesthetic in the electronic health record increased from a mean of 14% to 54%. PIV procedures with documentation of placement attempts increased from a mean of 47% to 70%. Through systems and culture change, awareness of the importance of pain prevention for venous access procedures increased, and patient-centered care improved with greater collaboration between nurses, providers, and families for venous access planning.

A Study to Assess Knowledge and Practice of Staff Nurses Regarding Care of Peripheral Intravenous Line (During Cannulization) Among Neonates at Selected Hospital in Jaipur with a View to Develop an Information Booklet

A Study to Assess Knowledge and Practice of Staff Nurses Regarding Care of Peripheral Intravenous Line (During Cannulization) Among Neonates at Selected Hospital in Jaipur with a View to Develop an Information Booklet

Total pulmonary resistance as assessed by non-invasive pressure-flow plots is related to exercise capacity in Fontan patients

Abstract Background In Fontan patients, the slope of invasively measured pulmonary artery pressures plotted against cardiac output (CO) during exercise has prognostic significance. We propose a methodology using exercise echocardiography combined with cardiopulmonary exercise testing and simultaneous peripheral venous pressure measurements (CPET-echo-PVP) to calculate PVP/CO slopes as a non-invasive alternative. Purposes This study aimed at assessing (1) PVP/CO slopes and (2) their relationship with peak oxygen consumption in Fontan patients. Material and Methods Consecutive adult Fontan patients seen in the outpatient clinic at UZ Leuven, Belgium were included in the study. All patients underwent CPET-echo-PVP (peripheral intravenous line connected to the pressure transducer zeroed at the mid-axillary level). Bloodwork was performed, including N-terminal prohormone of brain natriuretic peptide (NTproBNP). The PVP/CO slope was calculated as a linear approximation using linear regression analysis from pressure-flow plots for each patient. Univariable regression analysis was performed to identify potential determinants of PVP/CO slope. Results In total 20 patients (mean age 30.5±10.4 (range 20-60), 11[55%] females, dominant left ventricle in 15 [75%]) were included. NT-proBNP was 297±235 pg/mL. Patients performed staged exercise test achieving workload of 102±30 Watts with a peak oxygen consumption (peakVO2) of 19.2±3.8 mL/kg/min. During exercise cardiac output (CO), heart rate (HR) and PVP all increased (mean difference: 4.1±2.2L/min, 57±26bpm, 10.4±5.9mmHg, respectively). Stroke volume index (SVind) increased from baseline to peak exercise in 9 (45%) (mean difference -2.6±12.0mL/m2). The average PVP/CO slope was 2.21±1.53mmHg/L*min, with the value exceeding 3mmHg/L*min in 5 (25%) patients. PeakVO2, peak Workload during exercise, NTproBNP, New York Heart Association (NYHA) class, and rest-to-peak change in tissue-Doppler e’ (delta e’) of the lateral wall of dominant ventricle were significantly related to the PVP/CO slope (all p<0.05). Conclusions CPET-echo with PVP is a reliable method to identify determinants of exercise limitation in Fontan patients. The PVP/CO slope, which reflects total pulmonary resistance, is indeed related to peak oxygen consumption, heart rate reserve and diastolic function. Since it reflects hydraulic load to the systemic venous system it may be an important target in Fontan patients.

Abstract 17521: Esmolol-Associated Skin Necrosis: An Uncommon Adverse Reaction

Background: We report a case of a patient admitted to the cardiac care unit for evaluation of a non-ST-elevation myocardial infarction (NSTEMI) in the setting of atrial flutter (2:1) who developed a bullae and skin necrosis secondary to esmolol infusion. Case presentation: A 48-year-old male with a past medical history of hypertension presented with exertional chest pain with associated shortness of breath and palpitations and was being evaluated for NSTEMI. Vitals were significant for blood pressure of 191/115 and heart rate of 125. Labs were significant for troponin I of 33.16 (<=0.15 ng/mL), which peaked at 38.24, and creatinine of 2.5. Electrocardiogram demonstrated atrial flutter 2:1 conduction with a rapid ventricular response. While in the cardiac critical unit, he was placed on an esmolol drip for rate control. Twenty-four hours after administration of the esmolol through a peripheral intravenous line (PIV), the patient began to feel pain with moderate edema around the site of the injection. The PIV was removed, and cold compresses were applied. Approximately 5-7 hours later, the patient developed multiple ring-like bullae around the injection site. Physical examination was noted for cold and tenderness to palpation with paresthesias. General surgery was consulted for compartment syndrome, which was ruled out. The cutaneous changes progressively worsened through admission, persisting in size and appearance with rupture and ulceration, and necrosis one week later (see image 1). Conclusion: Although rare, esmolol can lead to skin necrosis and early identification is necessary for appropriate intervention including cessation of the culprit agent.

Cause analysis and nursing strategy of chemotherapy-induced phlebitis in cancer patients with peripheral intravenous line placement

Cause analysis and nursing strategy of chemotherapy-induced phlebitis in cancer patients with peripheral intravenous line placement

Therapeutic plasma exchange for neonatal hepatic failure

We report a case of therapeutic plasma exchange in a neonate with fulminant liver failure. A six-day old, 2800-gram baby was referred to our medical center for evaluation and treatment of fulminant hepatic failure. The working diagnosis at admission was gestational alloimmune liver disease, and therapeutic plasma exchange was proposed. A double volume plasma exchange was successfully performed, using the Spectra Optia apheresis system, primed with packed red blood cells. Access was obtained via a radial artery catheter and a peripheral intravenous line. On hospital D-14 a diagnosis of E3 deficiency was confirmed, and disease-specific therapy was started. Automated TPE using peripheral arterial and venous catheters may be safely performed in neonates, and should be considered in the treatment of a variety of disorders including neonatal fulminant hepatic failure.

Incidence of phlebitis among children having peripheral intravenous line in selected hospital, Siliguri

Background: Vascular access is the most common and widely used medical device in hospital setting especially peripheral intravenous line rather than central venous line and it is more essential in the pediatric and newborn group in accessing and maintaining a safe and reliable venous access for continuous management. Though it is the most common procedure, complication like phlebitis, extravasation, induration, dislodgement related to PIVC are also high. Methods: A prospective cohort study which included 86 children of age 1-7 years admitted in pediatric ward in selected hospital, Siliguri during the year 2023 in the month of May and June. Objective of the study was to find out the incidence of phlebitis among children admitted in pediatric ward. Observational method was adopted to collect data from the participants. Jackson’s VIP scale and FLACC scale was used to collect data along with demographic variables and peripheral intravenous catheter characteristics. Results: The study revealed that all the 86 children developed phlebitis where 64% of children developed phlebitis Grade 2 of phlebitis and 19% grade 3 on day 2 from the day of insertion where on day 3 8% had grade 2 and 9% had grade 3. The mean duration of PIVC was 53.11±0.87 hours and the major risk factor associated with phlebitis was site of insertion (OR=33.8, 95% CI-0.5, 207). Conclusions: By identifying early signs of phlebitis among children, one can manage it at appropriate time and can reduce the further complication related to the PIVC.

Augmentation of peripheral venous diameter for ultrasound-guided peripheral intravenous line insertion

ObjectivesUltrasound-guided intravenous line placement is utilized often in the emergency department for venous access in patients whose veins are difficult to cannulate by traditional methods. This study aims to identify specific interventions that will augment venous cross-sectional area. MethodsResidents and medical students volunteers each had their basilic vein identified using the linear array probe on an ultrasound. The area of the vein was measured with no intervention with the arm positioned parallel to the floor as well as approximately 45 degrees below the level of the bed. These two positions were repeated with the following interventions: one standard rubber tourniquet applied proximal to the vein measurement, an additional rubber tourniquet applied proximal to first tourniquet, blood pressure cuff inflated to between 160 and 200 mmHg applied proximal to the vein, CAT battle tourniquet application proximal to measurement site, and soaked warm towel applied to brachium for up to one minute. The primary outcome was to evaluate the increase in venous cross-sectional area from the baseline measurement after the interventions. ResultsWe had 41 participants in this study. All interventions were statistically significant in increasing venous cross-sectional area as compared to no intervention, with the most significant augmentation being from the CAT battle tourniquet (mean change +7.32 mm2, 95% CI, 5.73–8.91 mm2) . The change in position of the arm, was not statistically significant for any intervention except for the CAT tourniquet (mean change −1.74 mm2, 95% CI, −0.54 to −2.93 mm2). There was no significant difference between two tourniquets and blood pressure cuff (mean change +0.58 mm2, 95% CI, −1.13 to +2.29 mm2), but there was a significant increase in cross-sectional area with CAT tourniquet use compared to blood pressure cuff (mean change +1.62 mm2, 95% CI, 0.29–2.95 mm2). Lastly, two tourniquets increased cross- sectional area compared to one tourniquet (mean change +2.20 mm2, 95% CI, 1.14 − +3.26 mm2). ConclusionsThis study identified several potential interventions for maximizing venous cross-sectional area on ultrasound. All the tested interventions resulted in statistically significant increases in cross-sectional area. Arm positioning did not show significant changes in most interventions, with the exception of the CAT tourniquet. Further studies should be performed on how these maneuvers affect success in ultrasound-guided intravenous line placement.

Comparison of extravasation events related to the peripheral administration of vasopressors prior to and following implementation of an institutional protocol

AbstractIntroductionFollowing adequate fluid resuscitation, vasopressors are often utilized to maintain perfusion in shock states. Traditionally, vasopressors are administered via a central venous catheter (CVC) to attempt to minimize extravasation events. New literature advocates for peripheral vasopressor administration when CVC placement could lead to a delay in care. The purpose of this study was to compare extravasation events during vasopressor administration via a peripheral intravenous line (PIV) prior to and following the implementation of an institutional peripheral vasopressor protocol.MethodsThis was a single‐center, retrospective, observational study conducted at a large academic medical center. Adult patients admitted to an intensive care unit (ICU) from September 2018 to 2020 who received continuous infusion vasopressors were included. Vasopressors evaluated were norepinephrine, epinephrine, phenylephrine, dopamine, and vasopressin. The primary outcome evaluated extravasation events prior to and following the implementation of an institutional peripheral vasopressor protocol.ResultsOf the 3430 patients included, 1532 and 1898 patients were in the pre‐ and post‐protocol implementation groups. Following protocol implementation, there was an increase in PIV utilization, improvement in ultrasound‐guided PIV placement (17% vs. 26%, p < 0.001), and line assessment every 2 h (74% vs. 90%, p < 0.001). Less non‐compliance in vasopressor infusion rates (40% vs. 24%, p < 0.001) and PIV location (18% vs. 10%, p < 0.001) were also observed following protocol implementation. A total of 58 extravasation events occurred in both groups, 15 confirmed events and 43 suspected events. Following protocol implementation, there were less extravasation events (2.4% [n = 37] pre‐ vs. 1.1% [n = 21] post‐protocol p = 0.003).ConclusionFollowing the implementation of an institutional protocol, there was a reduction in extravasation events, an improvement in ultrasound‐guided PIV placement, and the use of peripheral infusion practices associated with increased safety. Additional studies are needed to determine the optimal peripheral vasopressor protocol to reduce CVC use and maintain reduced extravasation events.

Evaluating the Effect of Nursing-Performed Point-of-Care Ultrasound on Septic Emergency Department Patients.

Introduction Nursing-performed point-of-care ultrasound (NP-POCUS) studies have been performed on applications such as ultrasound-guided peripheral intravenous line placement and assessing bladder volume. However, research on the use of NP-POCUS in the management of septic patients remains limited. The purpose of this quality improvement study was to investigate how NP-POCUS could impact fluid treatment decisions affecting septic patients in the emergency department (ED)using a focused IVC and lung ultrasound protocol. Methods Nurses received standardized training in POCUS and performed inferior vena cava (IVC) and lung ultrasound scans on septic patients in the ED at predetermined intervals (hours: zero, three, and six). Based on their findings, they were asked to make recommendations on fluid management. Emergency physicians (EPs), both residents and attendings, are providing recommendations for fluid management without the use of ultrasound, which is being compared to the nurse-driven POCUS assessment of fluid management. EPs reviewed the NP-POCUS assessments of patient fluid status to determine nursing accuracy. Results A total of 104 patients were scanned, with a mean age of 60.7 years. EPs agreed with nursing ultrasound assessments in 99.1% of cases. Nursing ultrasound images changed management or increased physician confidence in current treatment plans83.7% and 96.6% of the time, respectively. Before reviewing saved nursing ultrasound images, EPs underestimated fluid tolerance in 37.5% of cases, overestimated fluid tolerance in 26% of cases, and correctly estimated fluid tolerance (within 500 ml) in 36.5% of cases. Throughout resuscitation, IVCs became less collapsible, the number of cases with B-lines was essentially unchanged, and less fluid was recommended. Conclusion This study demonstrated that nurse-performed POCUS is feasible and may have a meaningful impact on how physicians manage septic patients in the emergency department.

Use of Routine Emergency Department Care Practices with Deaf American Sign Language Users

BackgroundDeaf individuals who communicate using American Sign Language (ASL) seem to experience a range of disparities in health care, but there are few empirical data. ObjectiveTo examine the provision of common care practices in the emergency department (ED) to this population. MethodsED visits in 2018 at a U.S. academic medical center were assessed retrospectively in Deaf adults who primarily use ASL (n = 257) and hearing individuals who primarily use English, selected at random (n = 429). Logistic regression analyses adjusted for confounders compared the groups on the provision or nonprovision of four routine ED care practices (i.e., laboratories ordered, medications ordered, images ordered, placement of peripheral intravenous line [PIV]) and on ED disposition (admitted to hospital or not admitted). ResultsThe ED encounters with Deaf ASL users were less likely to include laboratory tests being ordered: adjusted odds ratio 0.68 and 95% confidence interval 0.47–0.97. ED encounters with Deaf individuals were also less likely to include PIV placement, less likely to result in images being ordered in the ED care of ASL users of high acuity compared with English users of high acuity (but not low acuity), and less likely to result in hospital admission. ConclusionResults suggest disparate provision of several types of routine ED care for adult Deaf ASL users. Limitations include the observational study design at a single site and reliance on the medical record, underscoring the need for further research and potential reasons for disparate ED care with Deaf individuals.

AIUM Official Statement: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel.

AIUM Official Statement: Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as Well as Safe Handling and Use of Ultrasound Coupling Gel.

983: PERIPHERAL VASOPRESSOR INFUSION FOR SHOCK: A QUALITY ASSESSMENT PROJECT IN A COMMUNITY ICU

Introduction: Vasopressor medications in shock are generally administered via central line but placement requires technical proficiency and in community ICU/ED settings, provider availability is not guaranteed around the clock. Evaluating the feasibility of peripheral vasopressor use in a real-world community hospital-based ICU allows us to explore alternative options. The primary objective was to assess the incidence of infiltration, skin necrosis, or limb loss resulting from peripheral vasopressor administration. A secondary objective was to assess the size and location of peripheral intravenous lines and the need for secondary central IV accesses. Institutional IRB approval was obtained. Methods: EMR records for all patients admitted with shock (any type) to a 12-bed community medical ICU receiving vasopressor support during 2018 were individually chart reviewed by a staff intensivist. The local sentinel event reporting system, and physician and nursing documentation were reviewed for any incidence of IV extravasation, or limb damage/loss. Pharmacy records of phentolamine/nitroglycerin paste orders ensured all cases of extravasation were captured. Results: There were 136 unique admissions requiring vasopressor support in 2018. 37.5 % of patients had central lines placed already while 44.9% of patients had vasopressors infused via peripheral IV. Of the 61 patients with peripheral IVs, 30 (49.2%) required placement of a central line. Vasopressors used included phenylephrine (47.1%), norepinephrine (41.9%), vasopressin (7.4%), dobutamine (2.9%) and epinephrine (0.7%). The average duration of vasopressor infusion through peripheral access was 592 mins. There were 8 episodes of infiltration amongst the peripheral IV group, with no episodes of skin damage or necrosis. The median IV size was 20 gauge, and the incidence of infiltration showed no significant association with gauge size (95%CI: -1.4, 0.61; P = 0.43). Conclusions: This dataset suggests that cutaneous infiltration of vasoactive medications is infrequent. Within this patient sample topical nitroglycerine or IV phentolamine, an antidote for cutaneous, drug-induced vasoconstriction, was rarely required. Gauge size in peripheral vasopressor administration appeared to make no difference.