Use of Inotropics by Peripheral Vascular Line in the First Hour of Treatment of Pediatric Septic Shock: Experience at an Emergency Department

Abstract

Objective: Mortality in pediatric septic shock remains unacceptably high.Delays in vasopressor administration have been associated with an increased risk of mortality. Current treatment guidelines suggest the use of a peripheral vascular line (PVL) for inotropic administration in fluid-refractory septic shock when a central vascular line is not already in place. The aim of this study was to report local adverse effects associated with inotropic drug administration through a PVL at a pediatric emergency department setting in the first hour of treatment of septic shock.Methods: A prospective, descriptive, observational cohort study of patients with septic shock requiring PVL inotropic administration was conducted at the pediatric emergency department of a tertiary care pediatric hospital. For the infusion and postplacement care of the PVL for vasoactive drugs, an institutional nursing protocol was used.Results: We included 49 patients; 51% had an underlying disease.Eighty-four percent of the children included had a clinical "cold shock." The most frequently used vasoactive drug was epinephrine (72%). One patient presented with local complications.Conclusions: At our center, infusion of vasoactive drugs through a PVL was shown to be safe and allowed for adherence to the current guidelines for pediatric septic shock.

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

“…In our study, 46% of patients initially supported with peripheral vasoactive infusion did not require central venous catheter placement for ongoing vasoactive infusion including nearly half of patients admitted to the PICU with septic shock. This finding is similar to an earlier prospective study evaluating 49 children with septic shock initiated on peripheral vasoactives in the emergency department, in which 39% of the patients admitted to the PICU did not subsequently have a central venous catheter placed (16). Patregnani et al (9) also reported that 38 of 102 PICU patients with shock were supported with only peripheral vasoactive administration.…”

“…Importantly, none of the extravasation events were associated with long-term disability. Similar findings were documented in pediatric patients presenting to the emergency department in septic shock who were given peripherally administered vasoactives and in a cohort of children receiving peripheral vasoactive therapy during critical care transport (16, 17).…”

Adherence to Pediatric Sepsis Treatment Recommendations at Emergency Departments

“…41 It has been shown that trying to place a central line delays prompt treatment of a critically ill patient at the PED where most children are initially seen. 41 Placement of a central line requires experience, time, and resources that may not be readily available in resource-limited settings. A median time of 1.5 hours for central line placement has been reported in adult patients with shock.…”

“…Nevertheless, 19% still tried to place a central line. In children, placement of a central line may require a lot of time, even in the hands experienced physicians 41 . It has been shown that trying to place a central line delays prompt treatment of a critically ill patient at the PED where most children are initially seen 41 .…”

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

“…In a single-center retrospective cohort of 102 children, the majority (62%) with septic shock and an overall mortality of 17%, 63% of patients required a CVC (8). 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.…”