|Year : 2021 | Volume
| Issue : 2 | Page : 63-64
Infusion of vasoactive drug through peripheral line: A myth or fact?
Muthu Chidambaram1, Ramachandran Rameshkumar2
1 Department of Pediatrics, Division of Pediatric Critical Care, Saveetha Medical College, Chennai, Tamil Nadu, India
2 Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||24-Jan-2020|
|Date of Acceptance||31-Jan-2020|
|Date of Web Publication||10-Mar-2021|
Dr. Ramachandran Rameshkumar
Department of Pediatrics, Division of Pediatric Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chidambaram M, Rameshkumar R. Infusion of vasoactive drug through peripheral line: A myth or fact?. J Pediatr Crit Care 2021;8:63-4
|How to cite this URL:|
Chidambaram M, Rameshkumar R. Infusion of vasoactive drug through peripheral line: A myth or fact?. J Pediatr Crit Care [serial online] 2021 [cited 2021 Apr 20];8:63-4. Available from: http://www.jpcc.org.in/text.asp?2021/8/2/63/311063
Vascular access is a fundamental intervention in pediatric intensive care unit. It is required for administering drugs, including vasoactive agents, nutrition, intravenous (IV) fluids, and blood products. It is usually obtained by peripheral IV cannulation, central venous line (CVL), peripherally inserted central line, or intraosseous access depending on the availability of resource, expertise, and urgency of a given clinical condition. Peripheral venous access can be easily obtained in children at a lower cost and with minimal expertise. However, it is limited by complications such as extravasation, inability to deliver high osmolality fluids, a limited rate of drug delivery, and difficulty in establishing during a shock state. CVL has the advantage of being rapid and reliable in its mode of drug delivery. In addition, the central venous pressure and mixed venous saturation can be measured which guide us in the titration of vasoactive drugs in critically ill children. However, the placement requires expertise and involves a higher cost. It is also associated with life-threatening complications such as pneumothorax, thrombosis, pleural effusion, hemothorax, and central line-associated bloodstream infection.
In the current issue of Journal of Pediatric Critical Care, Kumar et al. conducted a prospective observational study that compared the external jugular access with internal jugular venous access in pediatric shock. The question posed is relevant, especially from a low-middle income country (LMIC) where the expertise and high cost limit access to CVL. Early and timely initiation of vasoactive therapy is crucial for improving mortality in critically ill children with shock. Ninis et al. reported an association between delay in inotrope resuscitation and 22.6-fold increase in the septic shock mortality. Although the recent American College of Critical Care Medicine guideline recommends peripheral line inotropes until access to the CVL, it is not widely practiced. Even in modern era, many peripheral centers, do not prefer to start, inotropes through the peripheral line at the time of referral/transport because of the fear of extravasation and associated complications. This study helps us to demystify the myth of complications associated with the infusion of vasoactive agents through peripheral line.
Studies in adults and children established the safety of vasopressor administration via peripheral lines.,, The incidence of extravasation related to peripheral vasopressor administration has been reported from 2% to 15%.,, Studies reported administration of almost all types of vasoactive medications including dopamine, dobutamine, norepinephrine, epinephrine, and vasopressin via peripheral line., Few studies used the combination of vasoactive medications ranging from two to four via peripheral line without significant complications.,
The dose and duration of infusion are significant predictors of complications. Turner and Kleinman used vasoactive medications via the peripheral line up to 116 h without serious complications. Norepinephrine (75.6%) and dopamine (12.5%) are the common vasopressors implicated in local tissue injury and extravasation. The dose of dopamine was significantly higher (15 vs. 10 μg/kg/min) in patients who developed IV infiltrations. In the current study, the authors did not report the dose and duration of vasoactive drug administration and their relation to adverse events. Majority of the studies used the peripheral infusion of vasoactive drugs only for short term or during the transport of critically ill children., As the occurrence of complications depends on the duration of infusion, the reported adverse events might be underestimated. The authors used peripheral line for the entire duration of shock in the current study and reported no serious adverse events.
The choice of an ideal peripheral line in pediatric shock is not clear. Veins in the antecubital fossa were commonly used, and the external jugular vein (EJV) was less frequently preferred in one adult study. In the current study, the authors used EJV as a preferred peripheral line for administering medications in pediatric shock. EJV drains into the subclavian vein after a short course in the neck. Hence, it has the advantage of shorter circulation time and rapid onset of cardiac response, compared to cubital veins. Nevertheless, the EJV cannulation might be difficult in small infants because of short neck.
Vasoactive drug delivery through the peripheral line is often thought to be erratic and unpredictable. This is not studied in detail in previous studies. The authors used the time to reversal of shock as the surrogate outcome for ascertaining the drug delivery. The median time to reversal of shock was similar between EJV and internal jugular vein (IJV) group (48 vs. 46 h). This highlights the reliability of drug delivery through peripheral lines. The number of attempts, duration of procedure, and complication rate during insertion in the current study may be confounded by the residents' in experience performing the procedure.
The current study is one of the very few studies making a head to head comparison between central and peripheral lines in pediatric shock. Although this study is limited by the small numbers in the IJV group to arrive at a meaningful conclusion, it highlights the relative safety, low cost, and the requirement of minimal expertise for the use of peripheral venous access in pediatric shock in LMIC. Prospective multicentric studies with large sample size are warranted in the future.
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Conflicts of interest
There are no conflicts of interest.
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