Safety of Peripheral Intravenous Administration of Vasopressor Agents in Resource-limited Settings

Abstract

Background: Vasopressors are conventionally administered through a central venous catheter (CVC) and not through a peripheral venous catheter (PVC) since the latter is believed to be associated with an increased risk of extravasation. Placement of a CVC requires suitably trained personnel to be on hand, and in resource-limited settings, this requirement may delay placement. Because of this and in cases where suitably trained personnel are not immediately available, some clinicians may be prompted to utilize a PVC for infusing vasopressors. Objective: To determine the safety of peripheral intravenous administration of vasopressors among critically-ill children admitted at KNH Methods: This was a prospective observational study conducted at Kenyatta National Hospital’s paediatric ICU, main ICU and paediatric wards among admitted children aged between 1 month and 12 years. The participants were children on vasopressors through peripheral venous catheters. The study was estimated to take five months. The total sample was 49 children. Data collection was carried out using a standardized semi-structured questionnaire. Data analysis: Continuous variables e.g., age in months were summarized using median and interquartile ranges (IQR). Categorical variables e.g., gender (male/female), type of vasopressor and presence of extravasation or thrombophlebitis (yes/no) were summarized using frequencies and percentage proportions. Factors associated with complications of peripheral intravenous administration of vasopressors e.g., the dose of vasopressor and duration of administration on complications (yes/no) were assessed using binary logistic regression. Results were evaluated at 5% significance level using p-values and odds ratios/confidence intervals for odds ratios. P-values less than 0.05 were considered significant. Results: Of the 49 children, 31 (63.3%) were males. The median age was 21 months with an interquartile range of 10 to 28 months. The patients were admitted with septic shock except one with cerebral venous sinus thrombosis. The prevalence of extravasation injuries was 67% (95% CI 52%, 80%) and that of thrombophlebitis was 4% (95% CI 1%, 15%). The combined prevalence of vasopressor administration via peripheral lines was 69.4% (95% CI 54.4%,

81.3%). The extravasation injuries were grades one and two. The duration of cannula use of significantly associated with complications (P value <0.005), OR 1.14 (95% CI 1.05, 1.27). Age less than 2 years, upper limb cannulas and longer duration of inotrope infusion had higher odds of developing complications. Conclusion: The extravasation injuries that occurred in this study were either grade one or two with the majority being grade one. The prevalence of extravasation injuries in this study was high and incomparable to most of the findings from the literature. The prevalence of thrombophlebitis was low and generally within the findings of the published literature. Only one factor i.e., duration of cannula use was significantly associated with the development of complications of vasopressor administration via peripheral lines in children. Children less than two years, infusion of vasopressors on the upper limbs, smaller cannula gauge had higher odds of developing complications of vasopressor infusions via peripheral lines. Recommendations: We recommend that larger multisite studies be conducted to ascertain the findings of high prevalence of extravasation injuries and assess the risk factors for the development of complications of vasopressor infusion via peripheral lines. Utility of the study The outcome of this study will help understand the safety of administering vasopressors through peripheral lines. If the study confirms that this practice is not safe, then we will recommend the use of central lines for the administration of vasopressors. If the practice is safe, then it will be recommended that vasopressors be administered peripherally since their safety is confirmed and it will help save time.