A 2021 systematic review and meta-analysis (23 studies; 16 in adults, 17 in children [N= 16,443]) examined the incidence of local anatomic adverse events associated with peripheral intravenous (PIV) vasopressor administration in patients of any age cared for in an acute environment. Nineteen studies documented any adverse events, and 4 described serious occurrences, such as ischemia with skin necrosis and thrombophlebitis. Infiltration or extravasation resulting in modest local tissue responses, such as edema, erythema, blanching, phlebitis, pain, or mottling, was reported in 15 trials that documented adverse events. The trials that observed milder adverse events reported one long-term consequence, cutaneous discoloration in two participants. A pooled incidence proportion of adverse events associated with PIV vasopressor therapy in adults was 1.8% (95% confidence interval [CI] 0.1 to 4.8%), whereas in children was 3.3% (95% CI 0.0 to 10.1%). The subgroup analyses failed to identify any statistically significant effects linked to stratification based on variations in PIV location and size, clinical location, risk of bias or study design, or type or duration of vasopressor. The majority of studies showed high or moderate risk of bias. Based on these findings, the incidence of adverse events contributing to administering PIV vasopressors was minimal. The authors proposed that further investigation is warranted to examine how patient characteristics, vasopressor type and dosage, and PIV location and size affect the safety of PIV vasopressor administration. [1]
A 2023 prospective cohort study evaluated 287 patients with midline catheters for administration of vasopressors, 1,660 patients with vasopressors administered via peripherally inserted catheters (PICCs), and 884 patients with midline catheters who received vasopressors through a separate catheter. Results indicated a lower incidence of catheter-related complications in patients with midline catheters used to administer vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; p<0.001). After adjustment, midline administration of vasopressors was concluded not to be associated with catheter-related complications when compared to PICCs with vasopressors (adjusted odds ratio [aOR] 0.65; 95% CI 0.31 to 1.33; p= 0.23) or midline catheters with administration of vasopressors through a separate catheter (aOR 0.85; 95% CI 0.46 to 1.58; p= 0.59). However, midline catheters were associated with an increased risk of systemic thromboembolism compared to PICCs with vasopressors (aOR 2.69; 95% CI 1.31 to 5.49; 0.008) or midline catheters with administration of vasopressors through a separate catheter (aOR 2.42; 95% CI 1.29 to 4.54; p= 0.008). Ultimately, the study concluded that there was no significant association between vasopressor administration via midline catheter and catheter-related complications, yet caution was suggested due to the potentially increased risk of systemic venous thromboembolism. [2]
A 2022 abstract summarizes a retrospective chart review of patients receiving vasopressors through midline catheters (N= 203) over nine months. With an average of 32.2 hours per patient, the cohort's data collection resulted in 7,058 hours of vasopressor delivery via midline catheters, in which norepinephrine accounted for 5,542.8 midline hours (78.5%). There was no indication of extravasation during vasopressor administration. Between 38 hours and 10 days following vasopressor discontinuation, 14 patients (6.9%) had complications resulting in the removal of the midline catheters. Given the low rates of extravasation in midline catheters, midline catheters may serve as viable alternatives to central venous catheters for the infusion of vasopressors and should be considered as a route of infusion in critically ill patients. Additionally, practitioners may consider midline catheter insertion a first-line infusion route with minimal risk of vasopressor extravasation. [3]
A 2021 prospective, single-center study conducted in a closed ICU aimed to enroll 100 adult patients over six months and evaluate the administration of vasoactive medications via midline catheters for up to 72 hours. The study followed a protocol with defined maximum dosages: norepinephrine (0.15 mcg/kg/min), epinephrine (0.15 mcg/kg/min), vasopressin (0.04 units/min), phenylephrine (1.5 mcg/kg/min), dobutamine (10 mcg/kg/min), and dopamine (10 mcg/kg/min). Treating physicians alerted the study team when screening criteria were met. Subsequently, chart reviews were conducted before midline catheter insertion. The administration was shifted to another access point if a patient required a third vasoactive medication, exceeded defined dosages, or surpassed the 72-hour limit. While the study was ongoing at this publication, preliminary data on enrolled patients suggested no significant adverse events with the protocolled administration of vasopressors via midline catheters. However, only an abstract was available for scrutiny. [4]
A 2022 Argentine study had 60 midline catheters placed in 52 patients, four of whom were in prone positions. Dwell time ranged from 2 to 25 days. There was a 100% overall success rate and a 98% first-pass success rate. No phlebitis, occlusion, catheter dislodgement, or arterial punctures occurred, except for one catheter (1.6% of the total) which showed signs of infiltration. The incidence of catheter-related bacteremia and thrombosis was 1.5 and 3.1 per 1000 catheter days, respectively. Vasopressors, such as norepinephrine, were administered without complications at dosages as high as 3 mcg/kg/min. Most individuals had minor hematomas surrounding the insertion site that were not clinically significant. Based on their ongoing experience, the authors determined that ICU physicians may consider midline catheters as the preferred venous line in critically ill COVID-19 patients. Notably, these findings were observed in a single health institution outside of the United States, which may limit generalizability. [5]