Do you need to place a central line in every patient requiring initiation of vasopressors
A very common scenario we see in the hospital is a patient in shock during which the decision to start vasopressors is made. Is central venous catheter (CVC) placement necessary in all of these patients? A recent “Things We Do For No Reason” article in the Journal of Hospital Medicine addresses this question.
Highlights below:
– The concern for peripheral administration of vasopressors is related to reports of skin necrosis and subsequent complications in cases of extravasation. However, systematic reviews have challenged this thought, and the risk of extravasation through peripheral IVs resulting in tissue injury is rare. Therefore, risks of peripherally-administered vasopressors should be weighed against the risks of CVC placement.
– Delayed administration of vasopressors in shock can lead to increased mortality
– Vasopressors can be safely initiated and infused through peripheral IVs but thought should be given to PIV size, site, monitoring, and infusion settings.
– Times when a CVC should be used to administer vasopressors include:
- Pre-existing CVC in place
- Lack of reliable PIV given clinical conditions
- Requiring multiple or high dose vasopressors
- Requiring vasopressors for anticipated duration > 24h
- The following are the recommendations made by Block et al in the article:
- “In adults who require a single vasopressor, initiate the infusion through a 20‐gauge or larger IV proximal to the wrist and distal to the AC fossa, preferably placed under ultrasound guidance.
- Place a second functioning PIV as “back‐up” in case extravasation of vasoactive infusion occurs.
- Develop a monitoring protocol which includes IV site assessment in addition to recognition and management of extravasation.
- Place a CVC for patients requiring high‐dose or multiple vasopressors or for patients requiring vasopressors for longer than 24 h.
- Tailor policies and procedures to individual institutions through multidisciplinary quality enhancement and safety committees.
Article:
Block, J. M. , Boateng, A. & Madhok, J. (2022). Journal of Hospital Medicine, 17 (7), 565-568. doi: 10.1002/jhm.12844.