Peripheral Vasoactive Administration in Critically Ill Children With Shock: A Single-Center Retrospective Cohort Study*

Abstract

Management of fluid refractory pediatric shock requires prompt administration of vasoactive agents. Although delivery of vasoactive therapy is generally provided via a central venous catheter, their placement can delay drug administration and is associated with complications. We characterize peripheral vasoactive administration in a cohort of critically ill children with shock, evaluate progression to central venous catheter placement, and describe complications associated with extravasation.DESIGN: Retrospective cohort study.

Peripheral Vasopressors—Are We Avoiding the Central Issue Altogether?*

“…The rate of extravasation of a vasoactive agent out of a peripheral vein were similar in these two articles (Levy et al [1] and Peshimam et al [4]), although higher (3.5% vs 1.7%) in the transport cohort. It stands to reason that a peripheral catheter would have a higher risk of dislodgement on transport than while in the PICU.…”

“…Another cohort of 49 pediatric patients with septic shock in the emergency department, of whom 61% of patients ultimately required a CVC (9). The offering from Levy et al (1) adds to this literature, indicating that around half of septic shock patients, especially those who are larger, have lower illness severity, and are not mechanically ventilated, could avoid central lines. In addition, the increased use of PVA in patients with respiratory illness (bronchiolitis or LRTI) in their cohort could indicate that this group may do well avoiding CVCs.…”

“…Both of these reports include around 200 children, some of the largest to date. Safety of PVA remains the primary question, one of these articles (Levy et al [1]) pushes further to address the clinical scenarios where placement of a CVC might be avoided altogether. Timely initiation of vasoactives being a central element of the Surviving Sepsis Guidelines for Children (2) and they include explicit acknowledgment that peripheral use may be necessary.…”

“…In a single-center retrospective cohort spanning 6 years, Levy et al (1) describe 231 children supported with PVA. Compared with the group who had central administration of vasoactives, the PVA group were older, presented with a lower illness severity by Pediatric Risk of Mortality-III score and were more likely to be admitted in the nighttime.…”

Epidemiological Analysis of the Emergency Vascular Access in Pediatric Trauma Patients: Single-Center Experience of Intravenous, Intraosseous, Central Venous, and Arterial Line Placements

“…For fluid resuscitation, including transfusion of blood products, the flow rates of IO accesses are limited, and at least two peripheral IV lines are recommended, while the size of the cannulas should be large enough to deliver appropriate volumes rapidly [ 1 , 2 , 5 , 6 , 37 ]. Recent studies revealed that continuous administration of vasopressor agents through peripheral IV lines is feasible and safe [ 38 , 39 , 40 ]. However, special attention should be paid to the patency, functionality and securement of peripheral IV lines to avoid extravasation injuries.…”