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
