Although the 2021 Surviving Sepsis Campaign international guidelines on sepsis and septic shock recommend the use of norepinephrine as a PVI for the short-term management of hypotension in septic shock, this is a weak recommendation based on low-quality evidence. As a result, there is a lack of consensus on the safe and effective use of PVI in critical care.
Further, the Institute for Safe Medication Practices (ISMP) has identified multiple common causes of norepinephrine errors that occur during prescribing, administration, inventory and storage, and monitoring. ISMP also observed issues with similar-looking packaging and labeling for the different strengths of norepinephrine. ISMP also pointed out that there is a need to standardize norepinephrine doses, as both weight-based and non–weight based dosing options are available, as well as options in a facility’s pump library.
Investigators conducted an international multicenter, cross-sectional electronic survey to describe the current clinical practice regarding PVI administration in critically ill patients. The survey consisted of two parts: nine questions on background and demographic information and 23 questions on current clinical practice of PVI administration focusing on choice of PVI, PVI administration guidelines, frequency of assessing PVI site for extravasation injury, skin ischemia or skin necrosis, and treatment for PVI extravasation injury.
This survey was distributed to hospital pharmacists who managed critically ill patients and who utilized email discussion forums from several organizations. Pharmacists had the opportunity to participate in this survey via a post on the discussion forum. Among the organizations participating in this survey were the Society of Hospital Pharmacist of Australia, American College of Clinical Pharmacy, American Society of Health-System Pharmacists, United Kingdom Clinical Pharmacy Association, Canadian Society of Hospital Pharmacists, and Saudi Society of Clinical Pharmacy. Although all countries follow the International Surviving Sepsis Campaign for the management of septic shock, which recommends the use of peripherally administered norepinephrine until a central line can be placed, uncertainties about the use of PVIs still exist. National sepsis guidelines from the UK and Australia do not recommend a particular agent for PVI use, whereas the United States and Saudi Arabia do not have a separate national guideline for the management of sepsis or septic shock.
The main objective of the study was to determine how many hospitals administer norepinephrine as a PVI in critically ill adult patients. Secondarily, it was also to describe how norepinephrine is used with regards to maximum duration, infusion rate and concentration, and as a first-line PVI agent by country. The use of norepinephrine among those facilities that had a PVI guideline was compared with those without such guidance.
Of the 132 survey participants, 69% were from the U.S., followed by 12% from Canada, 8% from the UK, 7% from Australia, 2% from Saudi Arabia, and 2% from “other.” All participants were pharmacists, except for one nurse.
The investigators found that norepinephrine PVI was utilized in 86% of participating institutions. Half of the surveyed organizations had a median maximal duration of norepinephrine PVI of 24 hours. Slightly more than one-half (53%) of facilities set a maximum concentration of PVI norepinephrine at 16 mcg/mL, with the next most common maximum concentration of 11 mcg/min to 20 mcg/min utilized by one-third (34%) of facilities.
Despite the universal availability of the Surviving Sepsis guidelines, which recommended the use of PVI norepinephrine, 50% of institutions surveyed indicated that there was a preference to administer one or more other PVIs over norepinephrine, with the most common alternative PVIs being phenylephrine, which was used by 41% of American facilities; dopamine, which was utilized by 31% of Canadian organizations; and metaraminol, which was utilized by 82% and 89% of by the UK and Australia, respectively. (Metaraminol is not available in the U.S.) Saudi Arabia did not indicate a preference. PVIs other than norepinephrine were chosen because they were perceived to be associated with less extravasation injury and hypotensive risk.
More than one-half of institutions (51%) did not have PIV guidelines. Those organizations that had PIV guidelines were significantly (P <.01) more likely to provide a recommendation on the maximum PVI duration (76% vs. 22%), to identify a preferred PVI site of administration (which was most likely proximal to the antecubital fossa (69% vs. 31%), were more likely to have frequent monitoring of PVI administration sites (60% vs. 31%), and to offer treatment recommendations in the event of extravasation (88% vs. 66%) compared with institutions that did not have PVI guidelines.
This paper provides pharmacist who care for critically ill patients with valuable insight into the concerns and issues surrounding PIV use in clinical practice.
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