ER physicians are probably the experts about peripheral vasopressors. If you ask us if it’s ok to do it, we’ll tell you : ” Yeah, I do it all the time!” Pressors work fast, they work well, exactly what we like in the ED. Fast results, now we can call ICU and move to the next patient.

Wait a bit though.

Is it really ok? What about the risks of extravasation? Don’t we need a central line for it? Isn’t something we have to start in the ICU and not downstairs?

There are excellent blog posts out there and they are doing a great job to summarize the evidence. So please read them, especially this one.

SPOILER ALERT : peripheral pressors are an acceptable option associated with a low risk of extravasation and really rare complications. The only twist is that we should ensure it is a “good” IV (see criterias below) and there is a need for a protocol in case of extravasation management.

Extravasation

The biggest risk for a peripheral vasopressor is extravasation and the consequences are tissue damage and necrosis. Extravasation is infrequent (2%) and the major complications are rare (none reported in this study).

To minimize extravasation and, using what I have seen in the studies, my sine qua non criterias to start a peripheral pressors would be :

• used peripherally for ≤24 hours
• ≥20G needle
• contra-lateral to the blood pressure cuff measurement
• IV installed in the antecubital fossa or more proximally
• in the upper extremity
• IV site is checked every 2 hours by a nurse
• treatment protocol in case of extravasation

Management of extravasation

I really like this study protocol to manage extravasation. With 734 patients, the rate of extravasation was 2% and no major complications were reported. With such a low complication rate and the absence of randomization, it is hard to make big conclusions. But without major complications using this protocol, I think it is something worth using.

Here was their protocol in case of extravasation :

• Stop the peripheral vasopressor perfusion
• Aspirate the residual medication through the IV access
• Remove the IV catheter
• Prepare a total of 10mg of phentolamine blended with 10mL of normal saline, in a final concentration of 1mg/mL
• Using a 25G or 27G needle, inject 0,5-1mL aliquots in 5 separate injections around the edge of the extravasation site, using separate needle for each injection
• Apply nitroglycerine paste (2.5cm) to the extravasation area
• File a medication incident report

Upstairs / downstairs

I have often heard that we cannot start pressors in the ER, it needs to be started in the ICU. I am used to send patients for at least a 4 hours flight to the next ICU, so the concept of downstairs vs upstairs is non-existant in my head. I really think it is just some sort of a mental barrier, maybe something people invented to make it sound “exclusive”. But what if you are in a community hospital or expect a long transfert, would you delay it because you are not in the ICU? No. Do you really need someone’s approval to give treatment that you know is right? No.

The real question is what does the patient in front of me needs, not where he is. If he needs it, GIVE IT!

To conclude, starting pressors in the ER is safe and is an acceptable option. I feel this is just one of the technique or medication that are being liberalized (i.e. Point-Of-Care-Ultrasound had opposition initially by radiologists and now emergency medicine has become the leader in this field…).

Finished the time where it can only be started in one specific physical area, think about what is best for the patient, not where he is.