Low-Concentration Peripheral Norepinephrine

We’ve talked before about norepinephrine as a powerful and commonly used vasopressor in the ICU. This is often my go-to pressor for all types of shock, unless it’s cardiogenic shock or I’ve got reason to suspect that contractility is part of the problem. But, historically it has to be infused through a central venous catheter because of the potential risks of infiltration.

It used to be my practice to use phenylephrine when I needed a little bit of vasopressor but wanted to avoid a central line or the need for pressors was too urgent to wait for central line placement. This might be in the face of rapidly progressing, life-threatening shock when even the few minutes it would take to place a central line would be an unacceptable delay in pressor administration. Or, maybe the patient just needs a time-limited run of pressors, while recovering from anesthesia/procedural sedation, for example.

But, while phenylephrine is generally thought of as safe for peripheral administration, it’s really not the optimal vasopressor. I do use push doses of phenylephrine for transient hypotension associated with endotracheal intubation, for example. But, a phenylephrine drip is almost never what I want. If my patient needs a drip, they probably need norepinephrine.

In this episode of the Elective Rotation, Pharmacy Joe discusses the safety and efficacy of using low-concentration norepinephrine through peripheral venous access. Low-concentration norepinephrine has decreased risks in cases of infiltration as compared to standard-dose. Additionally, Tyler Jones has a great post over at Critical Care now discussing more broad use of peripheral vasopressors.

Either way, I think if a patient is sick enough to require norepinephrine at higher doses and/or longer periods of time, the risk of peripheral administration outweighs the risks associated with central venous access. So, put in the central line.

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