Using medications to increase blood pressure, called vasopressors, is invaluable in treating patients who have difficulty maintaining stable blood pressure. Vasopressors are usually infused through a central venous catheter (CVC), which is a flexible tube placed in the large vein of the neck, arm or groin. CVCs require a skilled clinician and often with an ultrasound to prevent complications such as a collapsed lung or bleeding. Alternatively, the infusion of vasopressors through a peripheral venous catheter (PVC), a thin tube placed in the smaller veins of the arm or hand has been avoided due to the risk of extravasation, which is the leakage of fluid to surrounding tissues. This can lead to potential tissue death requiring surgery. However, emerging research shows the safety of infusing vasopressors through a PVC, referred to as peripheral vasopressors. There is a growing interest in peripheral vasopressors for two main reasons: to expedite vasopressor initiation in patients with refractory shock and to avoid CVC placement and its potential complications. However, a standardized protocol for administration is lacking and many clinicians still avoid peripheral vasopressors due to lack of high-quality evidence. The investigators will examine the effectiveness of implementing a peripheral vasopressor protocol by conducting a feasibility study and assessing outcomes such as the safety of peripheral vasopressors and the acceptability rate of healthcare providers. By conducting this study, the investigators aim to provide the framework to conduct larger, multi-center trials and to provide high-quality data for the future use of a standardized peripheral vasopressor protocol.
Adults aged 18 or older who do not have a central line or PICC line already placed
Presence of shock requiring vasopressors at the following minimum doses: norepinephrine 5 mcg/min, phenylephrine 50 mcg/min, epinephrine 5 mc/min, dobutamine 5 mcg/kg/min
Urgent need for dialysis requiring placement of hemodialysis catheter
More than two vasopressors are required to maintain a MAP >65 on admission to the ICU
Pregnancy or suspected pregnancy
Parallel
Experiemental: Peripheral Venous Catheter
Procedure/SurgeryPatients older than 18 years of age who present with shock requiring vasopressors at the following minimum doses: norepinephrine 5 mcg/min, phenylephrine 50 mcg/min, epinephrine 5 mc/min, dobutamine 5 mcg/kg/min. Vasopressors are infused through a peripheral venous catheter (18 gauge or larger); however, patients are crossed over to the central venous catheter group if the maximum vasopressor dose is reached or more than two vasopressors.
The feasibility of recruitment
We hope to recruit at least 80% of patients who are eligible for the study.
Feasibility of data capture rate
We hope to have a data capture rate of at least 90%
Feasibility of acceptability rate of peripheral vasopressor protocol
We hope to have an acceptability rate of at least 90% by providers and nurses
Avoidance of central venous catheter placement
We will evaluate the crossover rate in patients who are initiated on peripheral vasopressors but ultimately require a central line due to escalating doses of vasopressors or poor venous access. We hope that 50% of patients will need a central line who have been initially allocated to the PVC group.
Assessing extravasation rates
This will be reported using descriptive statistics with a confidence interval of 95%.
Assessing alive and central line-free days
This will be reported as medians with a 95% confidence interval.
Assessing central-line associated blood stream infections
This will be reported as medians with a 95% confidence interval.
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