Evaluation of the safety and efficacy of peripheral vasopressors to decrease central line placement and associated bloodstream infections

Abstract

Background

In 2020, as a result of evidence of demonstrated safety of an initial pilot program, our institution set out to implement a peripheral vasopressor infusion protocol.

Objective

To evaluate the use of peripheral lines for vasopressor administration to reduce placement of unnecessary central lines and central line days.

Methods

This is an Institutional Review Board approved, single center retrospective chart review conducted as pre/post-analysis. Our hospital is a quaternary care, level 1 trauma center in Hartford, Connecticut that serves 100,000-120,000 patients annually. Patients >18 years admitted to an intensive care unit (ICU) were included if meeting protocol specific inclusion criteria pertaining to moderate expected duration and dose of vasopressor. Patients were excluded if vasculature not supportive of placement of two peripheral intravenous (PIV) sites, PIV sites without brisk blood return, had a limb restriction, or metacarpal line. All analyses were conducted with SPSS v. 26 (IBM; Armonk, NY 2019), using an a priori alpha level of 0.05 such that all results yielding p < .05 were deemed statistically significant. Primary efficacy outcomes of this study are number of central lines placed and number of central line days. The primary safety outcome is the number of extravasation events attributed to peripheral administration of vasopressors.

Results

Overall, 146 patients avoided central line placement constituting a 58.4% (p < .001) decrease in central line placement with peripheral vasopressor use. Out of 382 administrations there were a total of 14 extravasation events that occurred with peripheral vasopressor use in the post-intervention group. Implementation was associated with a statistically significant reduction in CLABSI occurrence.

Conclusions

The results of this analysis demonstrate that vasopressors can peripherally administered safely, when proximal to the antecubital fossa, at lower doses, and for short durations of infusion with minimal adverse events.

Introduction

Historically, vasopressors have been administered via central venous catheters (CVCs) given concern for extravasation associated with administration via peripheral venous catheters (PIV). However, recent evidence indicates that adverse event rates associated with peripheral vasopressor administration is lower than once thought (Prasanna et al., 2021).

Adverse effects attributed to vasopressor extravasation vary in severity from local tissue injury to tissue/skin necrosis, gangrene, and limb ischemia (Loubani and Green, 2015). Traditionally, to mitigate risk of tissue injury from peripheral administration, CVCs have been utilized for vasopressor administration. However, insertion of a CVC is not benign. Central lines are associated with mechanical, thromboembolic, and infectious complications, notably central-line associated bloodstream infections (CLABSIs). CLABSIs are preventable, yet they account for as much as one-third of hospital acquired condition-related deaths and contribute billions of US dollars in additional costs to the healthcare system (Central Line-Associated Bloodstream Infection, 2021; Groetzinger et al., 2022).

Additionally, central line placement is a sterile procedure requiring confirmation of placement prior to use. This procedure can lead to delayed initiation of vasopressor, which has been found to directly affect mortality in critically ill patients. One multicenter study of 8,670 patients found that each hour of delay in initiating vasopressor therapy in patients requiring pressor support was associated with a 2% increase of in-hospital mortality. Alternatively, utilizing PIVs to infuse vasopressors in hemodynamically unstable patients has been shown to be a safe and effective alternative to CVCs and may decrease time to initiation of vasopressor therapy (Lewis et al., 2019; Tran et al., 2020).

As a result of more recent evidence indicating safety of peripheral vasopressor administration and increased mortality with delayed vasopressor initiation, our institution elected to implement a pilot program to assist in decreasing central line placement, and subsequently, CLABSIs. This pilot allowed for peripheral administration of vasopressors, rather than requiring CVC placement. An initial, small, quality improvement (QI) study was published in May 2022. The investigation concluded that the pilot program prevented central line placement in 45 of 79 patients (57%) with only 3 possible extravasation events (3.7%), all of which were conservatively managed. The guideline/protocol has previously been published and described: of note there is no requirement for ultrasound guided PIV placement (Marti et al., 2022). The purpose of this study is to further evaluate the efficacy and safety of peripheral vasopressor administration to decrease rates of CLABSIs by reducing placement of unnecessary central lines and overall number of central line days. For the purposes of this study, an unnecessary central line was considered one whose only indication was vasopressor use for less than anticipated length of 72 h, or not requiring norepinephrine equivalent dose above protocol limits. Additionally multiple a-priori exploratory endpoints were evaluated including hospital and ICU length of stay, mortality, vasopressor choice, and time to vasopressor initiation. Finally, as previously reported, at our institution a central line was required to be inserted for all patients on vasopressors, with a rarely used, anecdotal, unwritten rule that phenylephrine was the only safe peripheral option. As such, guideline and pilot analysis aimed to provide a safe and evidence-based update to practice (Marti et al., 2022).

Materials and methods

Study design

The study titled Evaluation of the safety and efficacy of peripheral vasopressors to decrease central line placement and associated blood stream infections was approved by the IRB 9/2021. Approval number 2021-1-0303 in 9/2021. All procedures were carried out in accordance with ethical standards of the responsible committee on human experimentation and with Helsinki Declaration of 1975. Analyses were conducted as pre-/post- retrospective chart review. Pilot program start date was December 1, 2020 with implementation of the peripheral pressor guideline/protocol. Therefore, the pre-intervention, historical control group consisted of orders for ICU patients who received a vasopressor primarily through a central line from December 1, 2019, to November 30, 2020 in accordance with previous requirements. All orders for study-eligible ICU patients who received a vasopressor through a peripheral line per protocol from December 1, 2020, to November 30, 2021, comprised the post-intervention group.

Patients 18 years and older, of any sex, race, or ethnicity, without upper age limit, and admitted to an intensive care unit (ICU) were assessed for inclusion. Patients were included if duration of vasopressor infusion was expected to be less than 72 consecutive hours at the same infusion site, met peripheral catheter requirements (including 2 PIVs—one as backup in case of infiltration or extravasation), and received a low or moderate dose of norepinephrine (≤16 mcg/min), phenylephrine (≤200 mcg/min), vasopressin (≤0.04 units/min), or epinephrine (≤10 mcg/min) as defined in the institutional protocol. Patients were excluded from the post-intervention group if their vasculature did not support placement of two PIV sites, if sites did not have brisk blood return, if the patient had a limb restriction, a metacarpal line for vasopressor administration, or if the patient already had a CVC in place for alternative reason.

Outcomes

The primary efficacy outcomes of this study were number of central lines placed and overall number of central line days. The primary safety outcome was the number of extravasation events attributed to peripheral administration of vasopressors. The safety analysis includes a description of adverse events and management. Secondary outcomes include evaluation of patient-related risk factors for extravasation at baseline, incidence of CLABSI, ICU length of stay (LOS), hospital LOS, in-hospital mortality, as well as a prespecified subgroup analysis to evaluate initial choice of vasopressor for septic patients and time to initiation of vasopressor to assess adherence to Surviving Sepsis Campaign recommendations (Evans et al., 2021).

Power calculation and statistical analysis

The initial QI project completed by this group concluded that the peripheral vasopressor protocol was associated with a decrease in central line placement by 57%.(Marti et al., 2022) Using the previous analysis as baseline for significance, the sample size for the current study was planned to consist of a finite number of records, expected to be approximately 250 in each of the pre- and post-intervention cohorts, for a total sample of approximately 500. Sample sizes of 250 records per group were calculated to afford 82% power to reject the null hypothesis using a two-sided equal-variance t test and alpha level of 0.05.

Continuous, normally distributed, data are presented as mean and standard deviation (SD). For continuous data that are not normally distributed (e.g., LOS), or ordinal, a median with interquartile range (IQR) is used. Categorical data (e.g., adverse events) are presented as frequencies, using percentages. Inferential statistics were used to compare the two cohorts. Categorical data was compared using the Pearson chi square test and continuous data was compared using the student’s t test or Mann–Whitney U test, depending on data distribution. All analyses were conducted with SPSS v. 26 (IBM; Armonk, NY 2019), using an a priori alpha level equal to 0.05 such that all results yielding p < .05 were deemed statistically significant.

Results

Baseline characteristics

In total, 851 records were assessed for inclusion. Five hundred and nineteen records in the pre-intervention group and 332 records for the post-intervention group. After exclusions, there were 250 unique records included in both the pre- and post-intervention cohorts as presented in Figure 1. The most common reasons for exclusion in the pre-intervention group was lack of a central line due to transient (<1 h or not documented on record) vasopressor administration. The most common reason for exclusion in the post-intervention group was inappropriate documentation of peripheral administration despite presence of a central line.

Figure 1.

The flow chart describes the inclusion and exclusion of patients in the pre- and post-intervention groups.

Baseline characteristics were well-balanced between the groups and presented in Table 1. In both groups, there was a higher percentage of male subjects (54.4% vs 61.2%). Sepsis was the most common indication for vasopressor use in both the pre- and post-intervention groups (51.2% and 35.6%, respectively). Significantly more patients in the pre-intervention group required vasopressors for sepsis (51.2% pre- vs. 35.6% post-intervention patients) and cardiac arrest (12.4% pre-vs. 3.6% post-intervention patients, p < .001). However, more patients in the post-intervention group required vasopressors for neurogenic shock/autonomic dysfunction (1.2% pre- vs. 6.8% post-intervention patients) and other hemodynamic instability or undifferentiated shock (6.8% pre- vs. 17.6% post-intervention patients, p < .001).

Table 1.

Baseline characteristics for subjects included in the pre and post intervention study groups.

Characteristic	Pre-intervention (n = 250 subjects)	Post-intervention (n = 250 subjects)	p value
Age (years)—mean±SD	64.7±15.97	66.7±15.17	0.148
Body mass index (kg/m2)—mean±SD	30.43±8.33	29.28±8.01	0.118
Male sex—no (%)	136 (54.4)	153 (61.2)	0.124
Race—no. (%)			0.092
White	148 (59.2)	170 (68.0)
Black or African American	41 (16.4)	27 (10.8)
Asian	5 (2.0)	8 (3.2)
Other	51 (20.4)	39 (15.6)
Patient refused	5 (2.0)	6 (2.4)
Ethnicity—no. (%)			0.108
Not Hispanic or Latino	190 (76.0)	204 (81.6)
Hispanic or Latino	54 (21.6)	40 (16.0)
Patient refused	6 (2.4)	6 (2.4)
Vasopressor indication—no (%)			< 0.001
Gastrointestinal bleed, trauma or hemorrhagic/hypovolemic shock	22 (8.8)	22 (8.8)
Sepsis	128 (51.2)	89 (35.6)
Cardiogenic shock	10 (4.0)	12 (4.8)
Cardiac arrest	31 (12.4)	9 (3.6)
Hepatorenal syndrome	4 (1.6)	7 (2.8)
Procedural hypotension	12 (4.8)	17 (6.8)
Neurogenic shock or autonomic dysfunction	3 (1.2)	17 (6.8)
Hypotension secondary to sedation or other medications	17 (6.8)	24 (9.6)
Respiratory failure	6 (2.4)	9 (3.6)
Other hemodynamic instability or undifferentiated shock	17 (6.8)	44 (17.6)

Bolded p Values Indicate Statistical Significance.

The most common vasopressor utilized in both study groups was norepinephrine (58.4% of orders in the pre-intervention group vs. 59.6% of orders in the post-intervention group). Vasopressin and epinephrine were infrequently run peripherally in the post-intervention group (5 and 9 orders, respectively). There was a significant difference in the median duration of infusion for norepinephrine between study groups (median 16.97 h (6.56–38.80) in the pre-intervention group versus 14.22 h (6.18–27.95) in the post-intervention group (p = .036)). Vasopressor characteristics are described in Table 2.

Table 2.

Vasopressor characteristics for orders included in the pre and post intervention study groups.

Characteristic	Pre-intervention (n = 808 orders)	Post-intervention (n = 379 orders)	p value
Vasopressor type—no (%)			< 0.001
Norepinephrine	472 (58.4)	226 (59.6)
Phenylephrine	172 (21.3)	139 (36.7)
Vasopressin	105 (13.0)	5 (1.3)
Epinephrine	59 (7.3)	9 (2.4)
Duration of infusion (hours)—median (IQR)
Norepinephrine	16.97 (6.56-38.80)	14.22 (6.18-27.95)	0.036
Phenylephrine	7.91 (3.50-22.86)	11.50 (4.88-28.58)	0.120
Vasopressin	26.30 (9.07-51.52)	10.82 (7.71-42.62)	0.528
Epinephrine	6.38 (2.33-15.07)	10.67 (3.95-20.65)	0.380

Abbreviations: Interquartile range = IQR.

Bolded p Values Indicate Statistical Significance.

In the post-intervention group, the most common PIV used for vasopressor administration was the cephalic vein (70% of administrations), followed by the median cubital vein (21% of administrations). The breakdown of PIV utilized for vasopressor administration is depicted in eFigure 1.

Efficacy outcomes

Overall, 146 patients avoided CVC placement during their admission. Compared to the pre-intervention group, this constitutes a 58.4% (p < .001) decrease in central line placement with peripheral vasopressor use (see Table 3). No difference was found in median number of central line days between pre- and post-intervention groups [5 days (3-12) versus 7 days (3–12), p = .148]. However, there was a significant reduction in the occurrence of CLABSIs with the introduction of the peripheral vasopressor protocol. Incidence of CLABSI decreased from 12 infections (4.8%) in the pre-intervention group to 2 infections (0.8%) in the post-intervention group (p = .007). There was no difference in the ICU LOS, hospital LOS, and mortality between the study groups. Additionally, there were no reported PIV related infections nor septic thrombophlebitis related events.

Table 3.

Efficacy outcomes for subjects in the pre and post intervention study groups.

Outcome	Pre-intervention (n = 250 subjects)	Post-intervention (n = 250 subjects)	p value
Primary
Central line placement—no. (%)	250 (100.0)	104 (41.6)	< 0.001
Central line days—median (IQR)	5 (3-12)	7 (3-12)	0.148
Secondary
CLABSI occurrence—no. (%)	12 (4.8)	2 (0.8)	0.007
ICU LOS (days)—median (IQR)	6 (2-11)	5.50 (2.75-13)	0.495
Hospital LOS (days)—median (IQR)	12 (5-20)	13 (7-23.25)	0.089
Mortality—no. (%)	113 (45.2)	111 (44.4)	0.857

Abbreviations: Interquartile range = IQR; central line associated bloodstream infection = CLABSI; intensive care unit = ICU; length of stay = LOS.

Bolded p Values Indicate Statistical Significance.

Safety outcomes

Out of 382 administrations there were a total of 14 extravasation events that occurred with peripheral administration of vasopressors. Table 4 describes the safety outcomes for orders in the post-intervention group. The most common vasopressor to extravasate was norepinephrine with 11/14 events. However, this made up only 4.8% (11/227) of the total number of norepinephrine administrations in the post-intervention group. Three phenylephrine administrations had a documented event which constituted 2.2% of all phenylephrine administrations in the post-intervention group (3/139 administrations). Regarding infusion related risk factors, there was no difference in the maximum dose of norepinephrine or phenylephrine between those that extravasated versus those that did not. There was, however, a significantly longer median duration of infusion for orders with an event [27.0 h (20.35–84.35)] versus those without an event [12.6 (5.42–26.84)], p = .002.

Table 4.

Safety Outcomes for Orders Within the Post-intervention Group.

Outcome	Post-intervention without extravasation (n = 368 orders)	Post-intervention with extravasation (n = 14 orders)	p value
Extravasation incidence—no. (% total administrations)	368 (96.3)	14 (3.7)
Vasopressor type—no./total no. (%)			0.510
Norepinephrine	216/227 (95.2)	11/227 (4.8)
Phenylephrine	136/139 (97.8)	3/139 (2.2)
Vasopressin	5/5 (100)	0/5 (0)
Epinephrine	9/9 (100)	0/9 (0)
Duration of infusion—median (IQR)	12.6 (5.42 – 26.84)	27.0 (20.35 – 84.35)	0.002
Maximum dose (mcg/min)—mean±SD
Norepinephrine	16.01±26.79	11.10±5.75	0.382
Phenylephrine	123.94±90.82	126.67±64.29	Sample size too small

Abbreviations: Interquartile range = IQR; standard deviation = SD.

Bolded p Values Indicate Statistical Significance.

The analysis of patient-related risk factors for extravasation is summarized in eTable 1. There was no significant difference in the incidence of any previously reported risk factors for patients in the post-intervention group who experienced an extravasation event versus those who did not. Having a higher frequency of concomitant patient-related risk factors was not found to be significantly associated with an increased risk of extravasation.

The description of extravasation events, outcomes and management are described in eTable 2. In all 14 events documented minor complications of local irritation, infiltration, and phlebitis occurred. There were no instances of tissue necrosis, gangrene, or limb amputation. All events were conservatively managed with line discontinuation, utilization of an alternative PIV for vasopressor administration, warm compresses, and/or arm elevation. Two events were treated pharmacologically with phentolamine. Patients who experienced an extravasation event were more likely to be male and elderly. 10 patients who experienced an event were greater than 65 years of age. Although seven (50%) of the extravasation events documented occurred via the cephalic vein, there was no significant difference in the PIV location used for administrations for those that extravasated versus those that did not (p = .784).

Sepsis subgroup analysis

To assess adherence to the Surviving Sepsis Campaign recommendations, initial vasopressor choice and time to initiation of vasopressor were included as secondary outcomes in this study (see eTable 3). There were 128 subjects with sepsis in the pre-intervention group and 89 subjects in the post-intervention group. Norepinephrine was the most frequently used initial vasopressor selected for septic patients with 75.8% and 69.7% of septic patients receiving norepinephrine in the pre- and post-intervention groups, respectively.

Due to the retrospective nature of this study, only patients presenting to the emergency department (ED) were included in the analysis of time to initiation of vasopressor as these patients had clear time from presentation with sepsis to initiation. There was no difference in the time from presentation to vasopressor initiation in the pre- versus post-intervention group with a median time to initiation of 1.58 h (0.62–4.22) and 2.01 h (0.82–4.64), respectively, p = .654. Patients in the ED in the pre-intervention cohort were sometimes started on vasopressors peripherally until mandated central line could be placed so the analysis was repeated to compare if the route of initiation impacted the time to initiation. However, there was no difference in the time to initiation for pre-intervention subjects started on vasopressors peripherally [n = 42 patients, median 1.85 h (0.83–4.14), p = .838] versus started centrally [n = 15 patients, median 1.25 h (0.28–4.78), p = .417] when compared to the post-intervention group Table 5.

Table 5.

Trends in vasopressor use for the septic patient.

	Pre-intervention septic subgroup	Post-intervention septic subgroup	p Value
Septic patients—All, no.	128	89
Initial vasopressor—no. (%)			0.025
Norepinephrine	97 (75.8)	62 (69.7)
Phenylephrine	23 (18.0)	27 (30.3)
Vasopressin	6 (4.7)	0 (0.0)
Epinephrine	2 (1.6)	0 (0.0)
Septic patients—ED, no.	57	22
Initial vasopressor—no. (%)			0.548
Norepinephrine	49 (86.0)	20 (90.9)
Phenylephrine	5 (8.8)	2 (9.1)
Vasopressin	3 (5.3)	0 (0.0)
Epinephrine	0 (0.0)	0 (0.0)
Time to initiation of vasopressor (hours)—median (IQR)	1.58 (0.62 – 4.22)	2.01 (0.82 – 4.64)	0.654

Abbreviations: Interquartile range = IQR; emergency department = ED.

Discussion

Implementation of the peripheral vasopressor protocol at our institution resulted in a 58.4% (p < .001) decrease in central line placement as well as an absolute decrease of 4% in the incidence of CLABSIs (p = .007). This study identified a 3.7% total incidence of extravasation events, which remains consistent with the 3%–4% incidence rate reported previously in literature (Lewis et al., 2019; Marti et al., 2022; Tran et al., 2020). The results of this evaluation add to the body of evidence supporting safe use of vasopressors peripherally. At the same time, it is also the first that this group is aware of, demonstrating, not only statistically significant reduction in central line placement, but also CLABSI incidence with a number needed to treat of 25 patients. This study is one of the largest cohorts describing the use of peripheral vasopressors in recent literature, outside of anesthesia and operating room populations.

Notably, the indication for vasopressor differed significantly between the groups which may have impacted the LOS outcomes and central line days. However, while there were significantly more patients in the pre-intervention group with cardiac arrest and sepsis, these conditions are more likely to require a central line to be placed for other reasons. Interestingly, the median number of central line days was numerically longer in the post-intervention group (7 days) when compared to the pre-intervention group (5 days). This difference, while, not statistically significant (p = .148) was unanticipated. One explanation is that while reduction in unnecessary central line placement was accomplished, those ultimately requiring a CVC may have had similar reasons to pre-intervention group patients, and unnecessary central lines for short periods of time were no longer diluting the overall pool. These can be seen with interquartile ranges of 3–12 days for both groups.

Lewis et al. described comorbid conditions, utilized for analysis herein when designing safety endpoints, as patient-related risk factors for extravasation (Groetzinger et al., 2022; Lewis et al., 2019). However, none were found to correlate to increased risk of an infiltration or extravasation. The results of this study also refuted that a higher frequency, or coincidence, of comorbid conditions significantly increased risk of extravasation. There was also no association found pertaining to maximum vasopressor dose or PIV site when comparing patients who experienced an extravasation event versus those who did not. It is possible that our study was not powered to detect these differences, due to relatively small event occurrence.

The only significant difference between patients in the post-intervention group who experienced an extravasation event versus those who did not was longer duration of infusion observed for patients who had an extravasation event. For 10 of the 14 extravasation events, the duration of infusion had exceeded 24 h and 4 events exceeded the recommendation not to exceed 72 h at the same PIV site. Of the total 14 events, 12 required no intervention other than preventative line change and marking of the site, potentially indicating true extravasation did not occur. There were 2 events where phentolamine was administered to the surrounding site. Given that vasopressors are vesicants, an opportunity exists for education regarding extravasation management to facilitate safest practice. However, the lack of indication for pharmacologic management in these events suggests there may have been over-reporting of extravasation events.

In the 2021 update to the Surviving Sepsis Campaign International Guidelines, there was a recommendation to utilize peripheral lines for vasopressor initiation to avoid delays while awaiting central line access. The guidelines suggest that when using vasopressors peripherally, “they should be administered only for a short period of time and in a vein in or proximal to the antecubital fossa (Evans et al., 2021).” This recommendation, although noted to be low quality of evidence, is consistent with emerging literature citing duration of infusion and PIV access sites as the major factors in determining safe peripheral vasopressor administration. Norepinephrine continues to be the initial vasopressor of choice in the updated Surviving Sepsis recommendations (Evans et al., 2021). While our analysis did not show a significant difference in the time from presentation to vasopressor initiation for septic patients in the ED, the initial choice of vasopressor for these patients was more frequently norepinephrine in the post-intervention group (90.9%) compared to the pre-intervention group (86.0%) (Not statistically significant). Notably, Surviving Sepsis Campaign also advocates for ultrasound guided IV placement prior to administering vasopressors peripherally, our protocol did not require this, and resulted in no increased adverse events when compared to previously published literature. Further research is necessary to address this subgroup of patients before any conclusions can be drawn to say that peripheral vasopressor administration affects choice of agent.

This analysis has some limitations. Firstly, being a single-centered, retrospective, analysis limits its external validity. Secondly, we were unable to include all septic patients in the analysis of time from presentation to vasopressor initiation given the inability to retrospectively identify timing of decompensation requiring vasopressor due to documentation. Thirdly, the accuracy of line documentation relied on nursing to adjust the linked line for each vasopressor order. Consequently, we may not have captured changes in PIV site during an active infusion unless it was documented appropriately. This difficulty analyzing patient-specific factors also contributed to inability to accurately assign timing of sepsis onset and intervention. Additionally, documentation of extravasation management was minimal or absent in some events. The identification of infiltration or phlebitis relied upon review of flowsheet documentation in most cases. Lastly, this analysis is limited by the unknown impact of multiple waves of the Covid-19 pandemic. Contrary to our initial hypothesis, ICU/hospital LOS and central line days were not decreased in the post-intervention group. This could have been affected by two large Covid-19 waves during our post-intervention cohort. With the study period spanning from December 2019 to November 2021, each wave of the pandemic is represented in our study population. This may have affected a variety of outcomes including central line days, length of stay, and mortality. Finally, sepsis and cardiac arrest occurred more in the pre-intervention group and may have been associated with central line placement under duress and/or increased risk of contamination. However, undifferentiated shock diagnosis in the post-intervention group does not preclude either of these diagnoses in the acute setting and could represent coding or clerical error accounting for difference.

Conclusions

Overall, the results of this analysis demonstrate that vasopressors can be safely administered via peripheral IV sites proximal to the antecubital fossa, at lower doses and for short durations of infusion with minimal adverse events. The implementation of a peripheral vasopressor protocol not only avoided central line placement in 146 patients (58.4%) but also led to a significant reduction in CLABSI occurrence when compared to a historical cohort representing the previous standard of care where vasopressor administration required CVC placement. This data supports the ongoing use of our peripheral vasopressor protocol; however, further large-scale, multi-center studies are needed to confirm safety with routine use and to identify any additional risk factors for extravasation.

ORCID iD

Nicholas M Pugliese https://orcid.org/0000-0002-1195-5676