In the intensive care unit (ICU), vasopressors are administered when fluid resuscitation
alone cannot maintain adequate blood pressure in patients with shock. The standard of
care for continuous infusions of vasopressors is through a central venous catheter (CVC)
rather than a peripheral venous catheter (PVC). The use of CVCs prevents extravasation,
which can lead to local tissue ischemia resulting in necrosis. However, CVC placement is
not a benign procedure requiring a skilled clinician and the use of ultrasound guidance
to prevent complications such as pneumothorax, bleeding or erroneous arterial
cannulation. Furthermore, complications related to the maintenance of CVCs include deep
vein thrombosis (DVT), and central line-associated blood stream infections (CLABSIs).
These recognized complications occur in more than 15% of patients. There is a growing
interest in peripheral vasopressor use for two main reasons: to expedite vasopressor
administration in patients with refractory shock and to potentially avoid CVC placement
and it complications. However, there remains no standardized protocols and many
clinicians still believe that vasopressors must be infused through a CVC despite current
evidence showing the safety of peripheral vasopressors. However, to date only
observational studies have been performed. A randomized control trial is needed to
provide high quality data to improve the future use of peripheral vasopressors, which has
the potential to positively impact patient care.
The investigators will perform a feasibility study for the implementation of a peripheral
vasopressor protocol. They will also assess the safety of the peripheral vasopressor
protocol and evaluate clinically relevant outcomes, which will be listed below. The
investigators hypothesize that implementing a peripheral vasopressor protocol is feasible
and safe.
Aim 1: Adapt a peripheral vasopressor protocol and perform a feasibility study. The
investigators will conduct a feasibility study to determine the efficacy of a peripheral
vasopressor protocol. In collaboration with an ICU pharmacist, the investigators will
adopt a peripheral vasopressor protocol at Kingston Health Sciences Center to determine
the dosages and concentrations of each vasopressor. The participants will be randomized
1:1:1 into a low-dose peripheral vasopressor group vs. a dose peripheral vasopressor
group vs a high-dose peripheral vasopressor group vs a CVC group. Based on the admission
rates of our ICU, the investigators aim to recruit 25 patients into each group. They will
investigate the feasibility of recruitment, data capture rate, acceptability rate by
nursing staff and providers of the peripheral vasopressor protocol and avoidance rate of
CVC placement.
Aim 2a: Perform a safety assessment of peripheral vasopressor protocol. The investigators
will assess the safety of peripheral vasopressor administration after two months of
protocol initiation. Specific adverse events to be captured include extravasation (+/-
tissue necrosis), pneumothorax, arterial cannulation, and deep vein thrombosis. The
investigators will assess any differences in adverse events between the low-dose
peripheral vasopressor group vs the high-dose peripheral vasopressor group vs the CVC
group, which will be reported as proportions. The investigators hypothesize that
peripheral vasopressor use will be safe compared to the CVC group, with few to no adverse
events.
Aim 2b: Determine the impact of a peripheral vasopressor protocol on clinically relevant
outcomes. This feasibility study will investigate secondary outcomes such as alive and
central line-free days, infection rates including CLABSIs, mortality and ICU/hospital
length of stay. The investigators will report these outcomes as medians with 95%
confidence intervals.