Peripheral Vasopressor Administration - Considering Catheter Gauge

[0.9%NormalSarah, BSN, RN]

A recent discussion here on Allnurses was initiated to discuss the importance of lack thereof of reporting off the size and location of peripheral IV access during change of shift report. In a response regarding catheter size and the request to get a little more access if possible before my patient arrives in the ICU, I took the conversation off topic. The discussion regarding catheter size and drug infusions came up and while interesting, does not belong in the thread. So, I have opened a space for discussion on this topic and placed it in critical care since that’s typically where we run these drips, although I realize it also belongs in emergency care as these infusions are considered and most often started there.

In our discussion I stated that hospital policies with which I was familiar (at both hospitals where I’ve worked as well as two more where I completed clinicals in ICU) stated that peripheral vasopressors either were extremely discouraged, or if necessary, had to be run in a 20g or larger PIV in an upper extremity. Rightly so, other posters have called out the need for evidence. I know that medication admin resources I’d been provided in training and read myself have stated using a 20g or larger PIV, but why?

A recent meta-analysis looked at several studies over the last few years where peripheral administration of vasopressors and the prevalence of complications, specifically tissue injury from extravasation, were examined. The findings included the fact that complications related to the administration of vasopressors peripherally were a relatively low occurrence (Tran, et al., 2020). When compared with the risks associated with placing central access, it may be a preferred way to run vasopressors for a short time because maybe the patient won’t require prolonged use.

Included in the research was the size of catheter used reported by each study, and the sizes reported were 18g, 20g, and 22g. This meta-analysis found that the larger the IV catheter, the lower the occurrence of complications, although it was a small difference but still statistically significant (Trans, et al., 2020). However, the analysis acknowledges that further research is needed to validate this finding and establish this as a true guideline. This, coupled with evidence that suggests that delaying vasopressor or inotropic therapy may contribute to risk for in-hospital mortality (Beck, et al., 2014), a 22g PIV to get therapy started is more than adequate, especially for the short-term.

So why do some policies state the need for large IV catheter infusion? In short, I don’t know. Pfizer’s guidelines for norepinephrine administration simply state to run it into a large vein, but do not state anything about catheter size. Also, I have not found any recent studies specifically regarding catheter size and infusion of vasopressors or inotropes aside from one small single center study whose conclusions did not yield any new information not covered by the previously discussed meta-analysis (Nguyen, et al., 2021).

In conclusion, more research is needed to establish evidence-based practice guidelines for the short-term peripheral vasopressor administration specifically regarding IV catheter size. The thing I love about nursing is that there are millions of nurses with experience and perspectives that are so valuable and learning and growing our practice requires humility and looking at evidence. We must ask questions, especially of each other. Shoutout to the nurses that called me out on my statement in the other thread and helped me question my own experience and grow my knowledge base. The next time I get a patient up from ED with levophed running into a 22g, I’ll stop and remember this discussion and consider that the short time the patient has been on the drip is no cause for concern unless there are symptoms of extravasation and thank my ED colleague for getting that going. Please add your own perspectives to this discussion!

Sincerely,

Normal Sarah

References:

Beck V, Chateau D, Bryson GL, Pisipati A, Zanotti S, Parrillo JE, Kumar A; Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group. (2014). Timing of vasopressor initiation and mortality in septic shock: a cohort study. Critical Care, 12;18(3):R97. doi: 10.1186/cc13868.

Nguyen, T. T., Surrey, A., Barmaan, B., Miller, S., Oswalt, A., Evans, D., & Dhindsa, H. (2021). Utilization and extravasation of peripheral norepinephrine in the emergency department. American Journal of Emergency Medicine, 39, 55–59. https://doi.org/10.1016/j.ajem.2020.01.014

Tran, Q. K., Mester, G., Bzhilyanskaya, V., Afridi, L. Z., Andhavarapu, S., Alam, Z., Widjaja, A., Andersen, B., Matta, A., & Pourmand, A. (2020). Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis. American Journal of Emergency Medicine, 38(11), 2434–2443. https://doi.org/10.1016/j.ajem.2020.09.047

[Ado Annie, ASN, RN]

Thank you for doing the research. Similar discussions have been held among the M/S staff when patients who have developed an emergent situation have smaller-gage IVs. Invariably, an ICU or ER nurse gets crabby about it, says something derogatory, and takes time to try to start a larger IV, often without success! 

I try to use 20g or larger, but there are circumstances, especially with frail elderly people, when that is torture and an exercise in futility.

[Wuzzie]

A wise nurse once told me that the best IV to place is the one you can get in. This has served me well in my practice. 

For giggles ponder the following:

Would it be better to run vasopressors through a smaller, superficial vein where an infiltrate will be more likely to happen but also be discovered and dealt with sooner or a deeper, larger vein where an infiltrate is less likely but may take time to manifest increasing significantly the risk of tissue damage. Discuss. 
 

 

[0.9%NormalSarah, BSN, RN]

@Wuzzie yeah that is a good point, the sooner to catch the extravasation certainly the better. I personally have seen vasopressor extravasation in larger bore IVs, 18g and 20g and I do think it was caught fairly early due to the pain the patient felt. However like you said it may have been possible to catch it even earlier if the bore was smaller. I bet it also depends on location of the IV. 

In my critical care background, decades ago, our practice was to place the largest line that seemed practical in anticipation of needing to initiate an aggressive resuscitation, especially if blood products might be in the future poc. You used what ever was established in the field or the ED until you could put in something bigger and more stable under controlled circumstances.  In emergent situations we went immediately to intraosseous infusion until the central line could be established. 

[PMFB-RN, RN]

When running vasopressors in PIVs smaller is better. "Hemodilution is the solution"

   You want a relatively small catheter in a relatively large vein. Blood flow around the catheter helps deliver the medication where it's needed, and reduces vessel irritation. 

    I use 22 gauged or smaller when running vaso active drips in PIVs. 

[Tegridy]

Great review, unfortunately in the real world is a topic heavily surrounded by dogma and any other way besides whoever is in charge is wrong even though the data seems to be….. everywhere.

 

But at least we tend to be moving away from central lines and more toward PICCs in those without immediate need for “all the things” but still anticipated to take longer stay in the unit… minus those with the ckd

[offlabel]

As some have alluded to, it isn't the catheter size...it's the vein size and condition. We run epi and dopamine thru 24 or even 27 ga cathers  in neonates.  Norepi thru a 24 ga catheter in a frail, obese diabetic on steroids? Stabilize the cardiac output thru that but be making definite plans for reliable access. Epi thru a 27ga in a neonate? All the time before a uvc or uac. Bottom line is do what you always do and watch the site. If the inopressor requirements suddenly increase, suspect infiltration. But if the patient with poor access requires them, if better access is not being sought, you have bigger problems than the need for inopressors in the first place. 

[Wuzzie]

13 hours ago, Tegridy said:

But at least we tend to be moving away from central lines and more toward PICCs

Just to be clear, PICCs are central lines. 

[Tegridy]

7 hours ago, Wuzzie said:

Just to be clear, PICCs are central lines. 

Okay for the nitpicky people here “traditional” central lines…. Since obviously that was insinuated. 

 

?
 

[Wuzzie]

1 hour ago, Tegridy said:

Okay for the nitpicky people here “traditional” central lines…. Since obviously that was insinuated. 

We have a lot of new grads who may not be familiar with central lines and this site strives to provide them accurate information. They may not be aware that for a line to be called a “central line” it doesn’t matter where it’s inserted it only matters that it terminates in the central circulation. Given that this is a discussion of appropriate lines for the administration of vasopressors being clear about the types of line is important. 
 

The clap back wasn’t necessary. 

[PMFB-RN, RN]

On 1/24/2022 at 9:20 PM, Wuzzie said:

A wise nurse once told me that the best IV to place is the one you can get in. This has served me well in my practice. 

Nodays with small portable bedside ultrasound machines I can pretty much put and IV wherever I prefer it.