Robert A Levy1, Pamela D Reiter2, Matthew Spear3, Alison Santana4, Lori Silveira5, Shaina Cox6, Peter M Mourani7, Aline B Maddux8. 1. Department of Pediatrics, Section of Critical Care Medicine, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA. 2. Department of Pharmacy, Children's Hospital Colorado and Skaggs School of Pharmacy and Pharmaceutical Sciences, Anschutz Medial Campus, Aurora, CO. 3. Department of Pediatrics, Dell Children's Medical Center of Central Texas, Austin, TX. 4. Department of Pediatric Critical Care, Rocky Mountain Hospital for Children, Denver, CO. 5. Department of Pediatrics, University of Colorado Anschutz Medical Campus, University of Colorado, Aurora, CO. 6. PediPlace Pediatric Primary Care Clinic, Dallas, TX. 7. Department of Pediatrics, Section of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR. 8. Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
Abstract
OBJECTIVES: 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. SETTING: Single-center, quaternary PICU (January 2010 to December 2015). PATIENTS: Children (31 d to 18 yr) who received epinephrine, norepinephrine, or dopamine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared patients based on the initial site of vasoactive infusion: peripheral venous access (PVA) or central venous access (CVA) and, within the PVA group, compared patients based on subsequent placement of a central catheter for vasoactive infusion. We also characterized peripheral extravasations. We evaluated 756 patients: 231 (30.6%) PVA and 525 (69.4%) CVA patients. PVA patients were older, had lower illness severity, and more frequently had vasoactive therapy initiated at night compared with CVA patients. In PVA patients, 124 (53.7%) had a central catheter placed after a median of 140 minutes (interquartile range, 65-247 min) of peripheral treatment. Patients who avoided central catheter placement had lower illness severity. Of the 93 patients with septic shock, 44 (47.3%) did not have a central catheter placed. Extravasations occurred in four of 231 (1.7% [95% CI, 0.03-3.4]) PVA patients, exclusively in the hand. Three patients received pharmacologic intervention, and none had long-term disabilities. CONCLUSIONS: In our experience, peripheral venous catheters can be used for vasoactive administration. In our series, the upper limit of the 95% CI for extravasation is approximately 1-in-30, meaning that this route may be an appropriate option while evaluating the need for central access, particularly in patients with low illness severity.
OBJECTIVES: 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. SETTING: Single-center, quaternary PICU (January 2010 to December 2015). PATIENTS: Children (31 d to 18 yr) who received epinephrine, norepinephrine, or dopamine. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We compared patients based on the initial site of vasoactive infusion: peripheral venous access (PVA) or central venous access (CVA) and, within the PVA group, compared patients based on subsequent placement of a central catheter for vasoactive infusion. We also characterized peripheral extravasations. We evaluated 756 patients: 231 (30.6%) PVA and 525 (69.4%) CVA patients. PVA patients were older, had lower illness severity, and more frequently had vasoactive therapy initiated at night compared with CVA patients. In PVA patients, 124 (53.7%) had a central catheter placed after a median of 140 minutes (interquartile range, 65-247 min) of peripheral treatment. Patients who avoided central catheter placement had lower illness severity. Of the 93 patients with septic shock, 44 (47.3%) did not have a central catheter placed. Extravasations occurred in four of 231 (1.7% [95% CI, 0.03-3.4]) PVA patients, exclusively in the hand. Three patients received pharmacologic intervention, and none had long-term disabilities. CONCLUSIONS: In our experience, peripheral venous catheters can be used for vasoactive administration. In our series, the upper limit of the 95% CI for extravasation is approximately 1-in-30, meaning that this route may be an appropriate option while evaluating the need for central access, particularly in patients with low illness severity.
Authors: Paul A Harris; Robert Taylor; Robert Thielke; Jonathon Payne; Nathaniel Gonzalez; Jose G Conde Journal: J Biomed Inform Date: 2008-09-30 Impact factor: 6.317
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