Implementation of a nurse-led protocol for peripheral administration of vasoactive agents in critically ill patients:
Ee Ling Goh1, Fui Chung Wong2, Thi Thuy Linh Trang3
1Department of Emergency Medicine and Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, 609606, Singapore.
Background:
Vasoactive agents are commonly infused via a central venous catheter (CVC) because of concerns about extravasation. However, recent studies suggested that peripheral administration carries a low risk of extravasation, with minimal morbidity, when delivered under a protocol. Peripheral vasoactive agents can potentially facilitate early haemodynamic support and reduce CVC insertion and associated complications. We developed and implemented a multidisciplinary, nurse-led protocol with the aims of minimising extravasation events and avoiding unnecessary CVC placement.
Objectives:
The aim of this study was to evaluate the safety of a nurse-led protocol for peripheral administration of vasoactive agents for patients in the emergency department and intensive care unit.
Methods:
This was a protocol implementation initiative evaluated using a prospective, observational design. Adults who received at least one hour of peripheral vasoactive infusion were included. Protocol compliance, patients' demographics, dose and duration of vasoactive agents, extravasation events, and the number of CVCs avoided were documented.
Results:
A total of 217 patients, with a median age of 65 years, were included. Noradrenaline was the most commonly used agent (82.9%). Septic shock was the most common indication (46%). The median time to initiate peripheral vasoactive therapy was 23 min, and median duration of infusion was 3.4 h. Overall compliance rate was 66.8%, with most breaches due to exceeding the recommended duration and dose. Extravasation occurred in two patients (0.9%) and corresponds to an extravasation incidence rate of 33.8 events per 1000 peripheral vasoactive infusion-days (95% confidence interval: 4.09-122.25). Both patients did not develop any tissue injury following physical treatment according to the extravasation protocol. Ninety-one patients (41.9%) did not eventually require a CVC.
Conclusion:
Under a strict nurse-led protocol in our setting, peripheral vasoactive infusion was associated with a low incidence of extravasation. Comparative studies are needed to assess generalisability and clinical outcomes.
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