Vasopressor drips - central vs. peripheral?

[MELEA]

I had a patient from the OR last week. She was a small woman who had CABG X 4 and a mitral valve repair. She came back with a balloon pump, a right IJ cordis with a Swan, a left subclavian triple lumen catheter, a left femoral venous cordis and two forearm peripheral IVs. She was on dobutamine, milrinone and epi-cal. After some of the central lines had been removed, we were discussing which drugs (if any) we could run in the peripheral IV. This started a BIG discussion about hospital policy, common sense, CCRN policy etc.

Does ANYONE know if there are policies or "standards of care" documented about where certain drugs should be infused? Is it a standardized thing or does it vary hospital to hospital? I have come across lots of OPINIONS but nothing in "black-and-white".

[scoochy]

Consider the ph of the medication to be infused.

[CrabbyPatty]

Some meds are caustic and can cause extravasation. Why would the central line be removed if the patient was on some serious cardiac meds? It's much safer to run cardiac meds via a central line (especially if you already have it), than to risk losing your peripheral line(s) and not having IV access or causing damage to the patient due to extravasation.

Even with a central line, certain meds decrease peripheral circulation and eventually a patient's limbs lose all circulation. I had a patient like this who was @ risk for losing her hands AND feet because she was on a pressor for so long and her hands and feet were black from lack of circulation; family did not want to let go of her, but DID give approval to amputate her hands and feet if necessary!!! Luckily, they realized that she was not going to get better and made her a DNR. Very sad, but she had been sick for some time and she was only suffering

[pawashrn]

Crabbypatty, your patient's peripheral circulation didn't shut down because of where the drugs were infusing, but because of the drug you were infusing. I don't think you are going to have any hospital commit in black and white about where to infuse. Common sense is the biggest factor. vasopressors at high rates should go central. but all iv's with vaso. the site and the tract of the line should be assessed and charted on q1h ( appearance,sensitivity ) the bigger the vein the lesser the irritation. My opinion only, nothing to support my view.

[IrishMac]

Our hospital provides two online sources for looking up meds, Micromedex and Lexi-Comp. I believe if you look up Levo or Neo in Lexi-Comp it states it should be administered through a CL. Of course in a crisis a peripheral will do until a CL is established. But any extravasation has to be treated with Regitine.

[Flying ICU RN]

Does ANYONE know if there are policies or "standards of care" documented about where certain drugs should be infused? Is it a standardized thing or does it vary hospital to hospital? I have come across lots of OPINIONS but nothing in "black-and-white".

"Standards of Care", and the "Prudent Nurse Standard", dictate all that we do as Nurses. Add to your scenario the limitations of "Clinical Privileges" regarding central line insertion, and your job suddenly becomes easy and clearly defined.

A hemodynamically unstable patient requires appropriate and timely intervention, period. Would a layman, (Juror), consider it appropriate to allow a patient to have an adverse outcome from cardiogenic shock due to a fear of peripheral extravasation of a life saving therapy? Therein lies your prudent nurse standard, you infuse peripherally while your actions and documentation clearly show your attempts to circumvent the limitations of your clinical privileges, (i.e. central line insertion).

If your hospital policy does not specifically address this issue, (doubtful that they do not), then all drugs have Dosage and Route of Administration information clearly posted by both the manufacturers, as well as the FDA.

[grandmawrinkle]

Your hospital policy likely addresses this. At my facility, ALL vasopressors need to be ran centrally. If there is an emergency, the policy is that the pressor needs to be initiated in a large bore PIV and then a central line needs to be placed (physician's choice of which type) within 6 hours of starting the infusion. All pressors are huge extravasation risks - this includes epi, neo, levophed, dopamine and vasopressin.

The other gtts you spoke of have administration guidelines as well. I know some facilities these days only run amiodarone centrally -- mine doesn't, but if you've ever seen an amiodarone extravasation, it's an ugly thing. You should have a drug resource either on the web or in print at your facility -- put it to good use!

[CrabbyPatty]

Crabbypatty, your patient's peripheral circulation didn't shut down because of where the drugs were infusing, but because of the drug you were infusing. I don't think you are going to have any hospital commit in black and white about where to infuse. Common sense is the biggest factor. vasopressors at high rates should go central. but all iv's with vaso. the site and the tract of the line should be assessed and charted on q1h ( appearance,sensitivity ) the bigger the vein the lesser the irritation. My opinion only, nothing to support my view.

Although it may have sounded too confusing, I was trying to illustrate the fact that either peripherally OR centrally, vasopressors can be very damaging.

Peripherally, they are caustic and centrally they decrease peripheral circulation.

[msmiranda21]

In UK and Australia - if a patient is on inotropes then being hemodynamically unstable they need central line/s. We never run inotropes on peripheral lines unless at beginning of care where there isn't-then central lines are inserted. One lumen should be dedicated to these meds.