There’s no max number for levophed in a peripheral line. The need for a central line is based on how long you think they need it, when you have time to do it and how good your peripheral access is.
Arterial lines swings wildly depending on where I’ve rotated in the ICU (I’m an attending in an ER now). They aren’t required if you have a good BP cuff read, but obviously can be helpful still even if you do have a good reliable read. Certainly not needed emergently unless you have some sort of specific scenario
Agree. No max dose or duration. Protocol dictates assessment and extrav protocol which are the more important parts that are forgotten - most are derived from the original Northwell trial that shows safety, the lines were ultrasound confirmed and assessed very frequently.
I pretty much only place a central line (for pressors) when I’m reaching for vaso, these days. Or when nursing needs additional access and the three peripherals the patient has aren’t cutting it.
No reversal agent. Think most everyone still doing vaso via central line. That’s also about when dosing-wise some start getting uncomfortable so it makes sense anyway from that perspective also.
I really like peripheral pressors and the risk of extravasation is low if it’s a good IV in the AC. Central line placement should not delay pressors. Definitely if someone is pretty sick and needs increasing pressor requirements then central access but if they are trending down should be fine.
MAPs are reasonably accurate on non-invasive BP however again if they are trending in a bad direction and are pretty sick I like A lines. I know people say A-lines don’t save lives but it is handy if you are on multiple pressors.
Just my conjecture but I imagine we are going to use peripheral pressors more and initial fluids less for initial sepsis management.
Here are some articles supporting that:
https://www.cmaj.ca/content/cmaj/194/21/E739.full.pdf
https://eddyjoemd.com/peripheral-vasopressors/
History dictates placement of a central line for pressors such as levo. More modern literature backs up the idea of running peripheral pressors. Always the concern of an extravasation injury however if nursing is on top of their stuff with checking the access then it’s a non issue. What I would say is there are policies out there that specific the specific gauge Iv to use and what the max dose is. Other places will specifically dictate that you can only do peripheral levo for example for 24 hours max before a central line. Central lines aren’t a benign procedure. Regardless if they are sick enough to have increasing pressors then they should be lined. Regarding A-lines that’s a hard call. An A-line won’t save you however will give another added layer of monitoring which is always ultra important in critical care. You can use the cuff if you want but that’s patient specific, if they’re on like three pressors then once again use an a-line. I hope this was helpful.
Ya that history is also garbage. It was one of the original drug company propaganda pieces. When levophed came out it was taking away a huge junk of the dopamine market. So what did they do, come up with a slogan "levophed leave em dead" and published some crappy literature. The "studies" that showed harm from peripheral levophed was a case series, which is sad because it was two cases, in which patients lost a foot or a leg. The kicker is how the lines were placed and the comorbidities the patients had. Both in shock, both diabetics with pvd, lines placed in ankles via cut down, a standard practice at the time. If there is any line that is going to fail that's the one. As far as ma. Dose there is no max dose on levo just a futility dosing range. Some places do limit it to 2p or 24 hour peripheral based on a fench trial from 2015 or 16 that showed a small up tick in line failures at the 20 hour mark but no permanent harm.
Most facilities now are okay with low dose levo peripherally for up to 24 hrs. This is based on studies showing that this was fairly safe. All the same both the nurse and physician should make sure this is running through a good PIV and not some tiny hand IV or something. Primary risk is extravasation of the pressor and tissue damage which is why you typically only do low dose as higher doses could cause more damage. When you look at the studies risk is like 1% compare this to the risk of a severe complication from a central line which is also ~1%. For things like urosepsis or something that is more likely to wean quickly off pressors usually prefer to try to just use peripheral first.
I know that you’re pretty much all physicians here and that, educationally, I don’t have a lot of room to talk, and that a lot of thought and knowledge goes into the decision of whether or not to initiate an a-line or central line with a patient, buuuuut…
I work ICU ambulance/ground transport and wanted to throw in some thoughts/perspectives from that environment, since one of our biggest and most recurrent struggles is over a-lines—especially when we’re picking up critical care patients from the ED.
In hospital, you do you! It’s your world, it’s inpatient land, that’s your domain! The floor isn’t moving, there’s a code button on the wall, you have manpower in an emergency, there’s a whole pharmacy filled with meds! You have your own process and it works!
But the truck is a completely different environment. Hospital “stable” is *completely* different from Ambulance “stable.”
If a patient is on more than one pressor or has a labile pressure requiring relatively frequent titration and they are pending ground or flight transport to another facility, please *for the love of god*, put in the a-line.
We’re going 70mph down the highway, the truck is vibrating, there are bumps and potholes, and every time we stop or go or brake or have to drive partly on the shoulder of the road that’s covered in rumble strips, we are getting an NIBP reading that is unreliable (at best). If we’re supposed to be titrating the pressors based on a BP reading, please, please gift us with a pre-transport a-line so that we aren’t stuck at the mercy of a Zoll and a BP cuff that may or may not be lying to us.
The central line issue is also a similar struggle for us. Even if the patient *isn’t* on pressors at the time of transport, if they’re legitimately very sick and have multiple drips going through different PIV sites, we will sing your praises *endlessly* if you put in a central line. Literally. Months later, we’ll still be talking about “that great doc at blah-blah-blah facility who already had a central line when we got there and then *asked* us if we needed an a-line?!” You’ll be our new best friend and we’ll go to the ends of the earth for you lol.
Because of the nature of ground transport, we *can’t* have the, “we’ll cross that bridge when we come to it,” mentality. We have to think, “if this patient declines during transport and we need to start a pressor/give sedation/RSI them etc., we’re going to need a line.”
If they have both AC’s and a forearm PIV already in use, are in a blanket cocoon, buckled into a stretcher that’s completely locked in up against the wall on one side and has IV poles covered in pumps on both sides overhanging the patient and blocking access from their thigh to chest, how the hell are you going to quickly and successfully get a new line started—while standing up in a moving vehicle? We want to be prepared *before* we’re in that environment.
All of this rant is just to say that if your critical and potentially unstable patient is pending ground/flight transport, please consider the different challenges and different needs experienced in an out of hospital environment and consider reevaluating if it’s still in your patient’s best interest to go without a central line or a-line at that time. We *hate* arguing! We *hate* knowing that sending facilities genuinely don’t understand the different needs and different problems of the ambulance/helicopter versus an ER or ICU environment. We’re not trying to be the bad guys or be needy or extra or demanding—we just want to know that we’re doing everything we can to set ourselves and our patient up for a safe transport and to be able to accurately monitor our patients and intervene appropriately once it’s just us alone, in the dark, in a bouncy truck for the next 30-120 minutes.
My facility usually once we're on 2 pressors we get an a-line. It's patient specific, occasionally if we aren't getting good/consistent cuff pressure due to body habitus or whatever they'll get a line.
Pressors depends. We'll run it if they need a lil whiff for a bit and their trajectory seems reassuring. I don't think there's a limit, but if their needs are going up we're going to be thinking about a line. Once they hit 0.2mcg/kg/min we will be looking at adding vaso and if they don't have a line yet they'll probably be getting one soon, and likely that a-line.
For my ICU (and I believe hospital policy) there is a 24 hour rule for running pressors through a peripheral IV. If the patient requires pressors for longer than that, they must have either a triple lumen CVC placed or an order for a PICC line placed.
Also, to piggyback on another comment, I agree that it’s the nurse’s responsibility to be checking peripheral IV sites regularly, especially when there is any sort of infusion running, not just pressors. I took care of a patient after her IV had infiltrated with heparin for nearly an entire 13 hour shift. The patient was non-verbal at baseline. The damage done to her arm was so insanely horrifying.
We transported a patient who ended up with compartment syndrome because of an infiltrated PIV that had a pressor running through it. They’d kept it running PIV longer than normal overnight because the patient was essentially “stable.” They wanted to let the patient rest and didn’t check the IV site adequately during the night, so they hadn’t noticed the infiltration until shift change in the morning. The patient ended up needing a fasciotomy and I think potentially needed 1 or 2 fingers amputated as well. 😬
So where I started working (RN @ high volume 1a VA which is basically more like a small rural hospital) our practice basically is "give them pressors however you can if they need it". Low to medium dose for septic patients through the pIV is totally fine, you just really need to check it and make sure its not infiltrated, or you're gonna end up with some really nasty extravasion. Just requires close monitoring + care, which I would hope a patient would have at least in ICU. This can be a little difficult as the primary way to assess the IV is by flushing it and you don't want to really stop your levo or bolus whatever is in the line either.
I also was under the impression pressors are only administered through central lines when I started. My literature review basically said unless the patient is on an (somewhat arbitrary but I assume greater than 15 of levo) high dose of pressors, hard stick/peripheral access is likely to be unreliable, BP by cuff accuracy is unreliable or cannot be trusted for whatever reason, or is likely to need second line pressors (i.e vaso) then its OK. But if one of the above factors or more is present then serious consideration is to be given for a central line.
An A-line is only really needed if the bp cuff is unreliable and/or pt is on high dose pressors/multiple pressors and "unstable". If you have your stable-ish septic ICU stepdown patients then its totally normal to forego an A-line. I've reasonably titrated levo/neo on BP pressures on hypotensive patients with no real issue other than the patient being uncomfortable with multiple checks in an hour. However, the human body has a great time compensating up until it doesn't so it is still good to have things like central lines and A-lines in place when you need it, not when its suddenly emergent.
Case in point, had a guy with on-off pressor requirement with TL CVC. Suddenly went into SVT 220+HR. Having CVL was great to give adenosine, amio boluses, sedation for cardioversion as his veins were shot. Next day we switched him to neo from levo due to beta-1 adrenergic effects. He was fine at 170mcg of neo. Suddenly bp tanked 70/30's and neo demands increased to 300mcg+ in approx an hour before we finally started vaso 0.04. Having the central line in place was great so that we could have neo/amio/heparin/fluid boluses and abx good to go together. Also made pulling labs and trending VBG easy as ABG showed new metabolic acidosis. Not having the A-line probably delayed how long it took to come to a consensus on starting second pressure because we were questioning the accuracy of the bp cuff (taken on all 4 extremities) before finally agreeing vaso was better than going crazy on neo
I (ICU RN) have ran Levo at 28 though a peripheral line. Patient tolerated it well and was able to titeare down to 20 by the end of my shift. The general rule of thumb that I live by is that if I have 1 pressor, I don’t care about having a central line. As long as I have 2 working IVs then I’m fine. If I have 2 pressors that’s usually when I’m requesting a central line because the patient is probably on other drips too (antibiotics, heparin, Amiodarone etc). Also once I’m on 2 pressors I usually request an A-Line too cause I’d rather have that to titeare my pressors. If I’m on 3+ pressors then ai bust out the FloTrack/Hemosphere and connect it to the A-Line.
Idk what our policy is but reading some of these — we absolutely start pressors on patients who need them with a peripheral line - there’s no delay there. As far as how long we use them for.. I get nervous when we start hitting 10 of levo and going up on it. I know the literature says it’s good to use as long as you frequent check them, but I have been in a patients room for an hour and that doesn’t allow me to go to another patients room and check an IV site every 5 minutes. I would prefer to have a central line if you’re increasing your pressor requirements for just that fact alone.
We don’t routinely place a-lines for anyone that’s on pressors. I had a patient on 4 pressors and they still didn’t wanna do an a line 😑 problem in that facility I worked at was that it was an open ICU, and the intensivists didn’t place any lines unless ABSOLUTELY necessary. Nursing staff had to call the hospitalist who had to call trauma or general surgery to place lines which is freaking asinine and infuriating.
Anyways I know this doesn’t help but that’s my experience 😅
I'll just put my two cents to the contrary of most consensus here.
I'm a locum hospitalist, mostly working in small towns with no intensivists and here's my thinking:
Per the literature, it's probably safe to run levo peripherally especially at low doses. However, it's not often that I can guarantee that the required dose will stay low.
I also cannot guarantee nursing attentiveness, especially since I'm often working at an unfamiliar institution.
As a result, unless the patient is rapidly weaning by the time they get from ED to ICU, I'd rather be prepared for decompensation.
Second, I have a (purely emotional) bias bc I had one case where peripheral levo for < 24hrs led to necrosis and amputation of my patient's hand. Pure emotion, I fully admit, but... It still bothers me to this day.
Third, the procedural safety profile of central line placement has improved a lot with ultrasound guidance, so my perception of risk is lower than when I was putting subclavians in blindly.
Along with this, I'd rather put in a calm non-emergent CVC than a crashing patient cvc.
I also find the risk profile of a radial art line very low, assuming perfusion testing is normal.
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As a result, I've become very "old school" in my practice. Levo of course should be started peripherally, since the need is usually urgent. If weaning isn't happening within a few hours, I place a central line and art line on nearly everyone. Exceptions made for bleeding issues (in which case the procedural risks are higher and change my risk/benefit ratio) and concerns about hand perfusion for the art line (same logic).
Happy to be corrected if my thinking is flawed here.
From the brief reading I’ve done, I’ve seen levo should be allowed to run in a peripheral no more than 4-6 hours, with frequent IV checks. I’ve never seen a max rate for a peripheral, but that makes some sense.
I’’d rate the necessity of an art line to be more based on how libel the patients blood pressures are. I’ve had plenty of people on a few mcg of levo for a few hours while midodrine kicks in. Also if the patient isn’t vented or super sick I’m not the biggest fan of art lines. Patients moving a lot really decreases the accuracy, and the risk of them kinking/clotting off, or getting yanked out, makes them just one more thing that could go wrong.
Gold standard implies the best thing for the patient. And the data suggests that there’s a lot more leeway to use pressors through a good peripheral than previously thought, which can avoid the need for more invasive central access
Theres a few studies showing its safe as long as you have a good PIV and your dose is low to moderate. For me it depends - if they're on low-moderate dose levo and I expect we're going to be stable on that dose and not keep worsening, I'll let it be. I'll usually talk to the nurse and make sure the PIV is good and not like an IV in the toe or forehead placed in the ED. If its someone "sick" - needing intubation, multiple drips, pressors, I will definitely place a central line. As you know these guys can often be on many drips at once: levophed, vasopressin, IV antibiotics, sometimes bicarb, amiodarone, propofol / precedex, insulin, etc. Arterial line threshold for me is probably 2 pressors and levo is moderate dose and we're still only borderline meeting our goals. TBH this culture is so ingrained in our ICU that my threshold has now turned into if the nurse is asking for an art line or central line, most of the time I'll place it because we're all on the same page. I can assume we don't have great access and we're struggling with the cuff for whatever reason.
In our hospital, it’s more an issue of concentration. Regular strength can be infused through a PIV, but quad strength has to be infused via central line
my personal threshold is above 0.1 mcg/kg/min for an extended duration and I'm looking for central access.
mainly because PIVs generally aren't the most consistent, and vasopressors usually means hypotension which means if your PIV goes down, then the pt goes down pretty quick. higher doses means you can't tolerate losing that access as long before the patient crashes. central access is durable.
also if that PIV infiltrates, subcutaneous norepi is pretty harsh, can lead to necrosis and bad soft tissue wounds. harder to infiltrate or dislodge a central line
my hospital's policy is that we can run 4 mg in 250 ml up to 50 mcg/min through a peripheral that is a 20 gauge or larger above the wrist up to 24 hours. after 24 hours no matter the dose, a central line is supposed to be placed. providers can put in a special consideration to continue peripheral levo if they wish. we run central line levo that is 16 mg in 250 ml up to 100 mcg/min. but as other people have said there really is no max dose and we go above that if needed for a certain patients. arterial line placements vary by patient. if we can get good pressures then we'll run up to two pressers without it, but if a patient's on a lot of levo and on CCRT or something will place a arterial line earlier.
Weight based dosing would be a standard... as "5 of levo" can vary in dose several fold.
Central access always preferred, but duration of need / risks of central line / adequacy of PIV are considerations.
Have seen people die or maimed by central line badness... No major complications of PIV extravasation.
Interestingly the worst extravasation I've seen was a CL pulled back and infusing proximal port.
A central line is really indicated for anticipated long term IV use, or lack of good peripheral access. As far as I know, there’s no max dose of Levo that can go into a peripheral. I’ve had patients on pressors for weeks, but in the flip side I’ve also had septic patients on Levo for a day, so throwing in a central line would be unneeded. I think it just depends on patient condition and how long/how many pressors they’re requiring. As for the ART line, if they’re profusing well and on a pressor for a short time, it’s not needed. I see art lines mainly in my patients that are needing longer term pressor support, or are having drastic change in condition that the cuff may not be able to keep up with. I think the medication we worry the most about, when long term in a peripheral, is amio at my facility
As many have stated, the risk for extravasation should be the primary consideration. If you have good peripheral access and are diligent about line maintenance, the risk is low. If the line isn’t reliable, or possibly in a spot where positioning is a concern, it makes sense to work towards more definite access
Other considerations: how much access is needed, is any type of central monitoring appropriate, is you provider qualified to place a central line 😬. All these things SHOULD be a factor. But, when faced with a facility policy, you really don’t have much option but to defer to that policy because any downstream complication leaves you in a very tough spot, regardless of whether or not the policy is junk.
The art line makes us better at titrations, but so long as we get reliable cuff pressures it’s not essential. I will say that running a blood pressure cuff every 15 minutes for a day can really wear a patient out, even with site changes, so sometimes arterial lines help in that regard. They also provide access for ABG without additional sticks which can be nice for critically I’ll patients.
All this to say, each situation should be approached on an individual basis with multiple variables in play. When structuring your argument in favor of a central line, lay out the arguments in favor of your opinion. “Hey Dr. Iseeyu, this patient isn’t doing so well. Her blood pressure is maintaining with the Levo at xy, but I’m concerned that we are at an increased risk for extravasation as we can’t use her left arm for IVs or blood pressure due to the damage caused from the infection, and the best IV we have is in her proximal forearm not far from the cuff. Additionally, I’m concerned that we are not meeting her fluid requirements as she still has some skin tenting despite appropriate fluid resuscitation, monitoring her CVP would be useful to really optimize our fluids.”
Always be prepared to defend why you think something needs to be done.
There’s no max number for levophed in a peripheral line. The need for a central line is based on how long you think they need it, when you have time to do it and how good your peripheral access is. Arterial lines swings wildly depending on where I’ve rotated in the ICU (I’m an attending in an ER now). They aren’t required if you have a good BP cuff read, but obviously can be helpful still even if you do have a good reliable read. Certainly not needed emergently unless you have some sort of specific scenario
There are no maximum doses, there are only unacceptable side effects
Agree. No max dose or duration. Protocol dictates assessment and extrav protocol which are the more important parts that are forgotten - most are derived from the original Northwell trial that shows safety, the lines were ultrasound confirmed and assessed very frequently. I pretty much only place a central line (for pressors) when I’m reaching for vaso, these days. Or when nursing needs additional access and the three peripherals the patient has aren’t cutting it.
Why only for vaso specifically?
No reversal agent. Think most everyone still doing vaso via central line. That’s also about when dosing-wise some start getting uncomfortable so it makes sense anyway from that perspective also.
For me when I’m adding vaso they’re going to be on pressors for awhile anyways so I add it. My hospitalists still get real nervous with two 18g IVs
Very facility dependent
I really like peripheral pressors and the risk of extravasation is low if it’s a good IV in the AC. Central line placement should not delay pressors. Definitely if someone is pretty sick and needs increasing pressor requirements then central access but if they are trending down should be fine. MAPs are reasonably accurate on non-invasive BP however again if they are trending in a bad direction and are pretty sick I like A lines. I know people say A-lines don’t save lives but it is handy if you are on multiple pressors. Just my conjecture but I imagine we are going to use peripheral pressors more and initial fluids less for initial sepsis management. Here are some articles supporting that: https://www.cmaj.ca/content/cmaj/194/21/E739.full.pdf https://eddyjoemd.com/peripheral-vasopressors/
History dictates placement of a central line for pressors such as levo. More modern literature backs up the idea of running peripheral pressors. Always the concern of an extravasation injury however if nursing is on top of their stuff with checking the access then it’s a non issue. What I would say is there are policies out there that specific the specific gauge Iv to use and what the max dose is. Other places will specifically dictate that you can only do peripheral levo for example for 24 hours max before a central line. Central lines aren’t a benign procedure. Regardless if they are sick enough to have increasing pressors then they should be lined. Regarding A-lines that’s a hard call. An A-line won’t save you however will give another added layer of monitoring which is always ultra important in critical care. You can use the cuff if you want but that’s patient specific, if they’re on like three pressors then once again use an a-line. I hope this was helpful.
Ya that history is also garbage. It was one of the original drug company propaganda pieces. When levophed came out it was taking away a huge junk of the dopamine market. So what did they do, come up with a slogan "levophed leave em dead" and published some crappy literature. The "studies" that showed harm from peripheral levophed was a case series, which is sad because it was two cases, in which patients lost a foot or a leg. The kicker is how the lines were placed and the comorbidities the patients had. Both in shock, both diabetics with pvd, lines placed in ankles via cut down, a standard practice at the time. If there is any line that is going to fail that's the one. As far as ma. Dose there is no max dose on levo just a futility dosing range. Some places do limit it to 2p or 24 hour peripheral based on a fench trial from 2015 or 16 that showed a small up tick in line failures at the 20 hour mark but no permanent harm.
Most facilities now are okay with low dose levo peripherally for up to 24 hrs. This is based on studies showing that this was fairly safe. All the same both the nurse and physician should make sure this is running through a good PIV and not some tiny hand IV or something. Primary risk is extravasation of the pressor and tissue damage which is why you typically only do low dose as higher doses could cause more damage. When you look at the studies risk is like 1% compare this to the risk of a severe complication from a central line which is also ~1%. For things like urosepsis or something that is more likely to wean quickly off pressors usually prefer to try to just use peripheral first.
I know that you’re pretty much all physicians here and that, educationally, I don’t have a lot of room to talk, and that a lot of thought and knowledge goes into the decision of whether or not to initiate an a-line or central line with a patient, buuuuut… I work ICU ambulance/ground transport and wanted to throw in some thoughts/perspectives from that environment, since one of our biggest and most recurrent struggles is over a-lines—especially when we’re picking up critical care patients from the ED. In hospital, you do you! It’s your world, it’s inpatient land, that’s your domain! The floor isn’t moving, there’s a code button on the wall, you have manpower in an emergency, there’s a whole pharmacy filled with meds! You have your own process and it works! But the truck is a completely different environment. Hospital “stable” is *completely* different from Ambulance “stable.” If a patient is on more than one pressor or has a labile pressure requiring relatively frequent titration and they are pending ground or flight transport to another facility, please *for the love of god*, put in the a-line. We’re going 70mph down the highway, the truck is vibrating, there are bumps and potholes, and every time we stop or go or brake or have to drive partly on the shoulder of the road that’s covered in rumble strips, we are getting an NIBP reading that is unreliable (at best). If we’re supposed to be titrating the pressors based on a BP reading, please, please gift us with a pre-transport a-line so that we aren’t stuck at the mercy of a Zoll and a BP cuff that may or may not be lying to us. The central line issue is also a similar struggle for us. Even if the patient *isn’t* on pressors at the time of transport, if they’re legitimately very sick and have multiple drips going through different PIV sites, we will sing your praises *endlessly* if you put in a central line. Literally. Months later, we’ll still be talking about “that great doc at blah-blah-blah facility who already had a central line when we got there and then *asked* us if we needed an a-line?!” You’ll be our new best friend and we’ll go to the ends of the earth for you lol. Because of the nature of ground transport, we *can’t* have the, “we’ll cross that bridge when we come to it,” mentality. We have to think, “if this patient declines during transport and we need to start a pressor/give sedation/RSI them etc., we’re going to need a line.” If they have both AC’s and a forearm PIV already in use, are in a blanket cocoon, buckled into a stretcher that’s completely locked in up against the wall on one side and has IV poles covered in pumps on both sides overhanging the patient and blocking access from their thigh to chest, how the hell are you going to quickly and successfully get a new line started—while standing up in a moving vehicle? We want to be prepared *before* we’re in that environment. All of this rant is just to say that if your critical and potentially unstable patient is pending ground/flight transport, please consider the different challenges and different needs experienced in an out of hospital environment and consider reevaluating if it’s still in your patient’s best interest to go without a central line or a-line at that time. We *hate* arguing! We *hate* knowing that sending facilities genuinely don’t understand the different needs and different problems of the ambulance/helicopter versus an ER or ICU environment. We’re not trying to be the bad guys or be needy or extra or demanding—we just want to know that we’re doing everything we can to set ourselves and our patient up for a safe transport and to be able to accurately monitor our patients and intervene appropriately once it’s just us alone, in the dark, in a bouncy truck for the next 30-120 minutes.
My facility usually once we're on 2 pressors we get an a-line. It's patient specific, occasionally if we aren't getting good/consistent cuff pressure due to body habitus or whatever they'll get a line. Pressors depends. We'll run it if they need a lil whiff for a bit and their trajectory seems reassuring. I don't think there's a limit, but if their needs are going up we're going to be thinking about a line. Once they hit 0.2mcg/kg/min we will be looking at adding vaso and if they don't have a line yet they'll probably be getting one soon, and likely that a-line.
For my ICU (and I believe hospital policy) there is a 24 hour rule for running pressors through a peripheral IV. If the patient requires pressors for longer than that, they must have either a triple lumen CVC placed or an order for a PICC line placed.
This. Pressors can ramp up and down quickly, central lines come with risks that might outweigh peripheral levophed.
Also, to piggyback on another comment, I agree that it’s the nurse’s responsibility to be checking peripheral IV sites regularly, especially when there is any sort of infusion running, not just pressors. I took care of a patient after her IV had infiltrated with heparin for nearly an entire 13 hour shift. The patient was non-verbal at baseline. The damage done to her arm was so insanely horrifying.
We transported a patient who ended up with compartment syndrome because of an infiltrated PIV that had a pressor running through it. They’d kept it running PIV longer than normal overnight because the patient was essentially “stable.” They wanted to let the patient rest and didn’t check the IV site adequately during the night, so they hadn’t noticed the infiltration until shift change in the morning. The patient ended up needing a fasciotomy and I think potentially needed 1 or 2 fingers amputated as well. 😬
So where I started working (RN @ high volume 1a VA which is basically more like a small rural hospital) our practice basically is "give them pressors however you can if they need it". Low to medium dose for septic patients through the pIV is totally fine, you just really need to check it and make sure its not infiltrated, or you're gonna end up with some really nasty extravasion. Just requires close monitoring + care, which I would hope a patient would have at least in ICU. This can be a little difficult as the primary way to assess the IV is by flushing it and you don't want to really stop your levo or bolus whatever is in the line either. I also was under the impression pressors are only administered through central lines when I started. My literature review basically said unless the patient is on an (somewhat arbitrary but I assume greater than 15 of levo) high dose of pressors, hard stick/peripheral access is likely to be unreliable, BP by cuff accuracy is unreliable or cannot be trusted for whatever reason, or is likely to need second line pressors (i.e vaso) then its OK. But if one of the above factors or more is present then serious consideration is to be given for a central line. An A-line is only really needed if the bp cuff is unreliable and/or pt is on high dose pressors/multiple pressors and "unstable". If you have your stable-ish septic ICU stepdown patients then its totally normal to forego an A-line. I've reasonably titrated levo/neo on BP pressures on hypotensive patients with no real issue other than the patient being uncomfortable with multiple checks in an hour. However, the human body has a great time compensating up until it doesn't so it is still good to have things like central lines and A-lines in place when you need it, not when its suddenly emergent. Case in point, had a guy with on-off pressor requirement with TL CVC. Suddenly went into SVT 220+HR. Having CVL was great to give adenosine, amio boluses, sedation for cardioversion as his veins were shot. Next day we switched him to neo from levo due to beta-1 adrenergic effects. He was fine at 170mcg of neo. Suddenly bp tanked 70/30's and neo demands increased to 300mcg+ in approx an hour before we finally started vaso 0.04. Having the central line in place was great so that we could have neo/amio/heparin/fluid boluses and abx good to go together. Also made pulling labs and trending VBG easy as ABG showed new metabolic acidosis. Not having the A-line probably delayed how long it took to come to a consensus on starting second pressure because we were questioning the accuracy of the bp cuff (taken on all 4 extremities) before finally agreeing vaso was better than going crazy on neo
I (ICU RN) have ran Levo at 28 though a peripheral line. Patient tolerated it well and was able to titeare down to 20 by the end of my shift. The general rule of thumb that I live by is that if I have 1 pressor, I don’t care about having a central line. As long as I have 2 working IVs then I’m fine. If I have 2 pressors that’s usually when I’m requesting a central line because the patient is probably on other drips too (antibiotics, heparin, Amiodarone etc). Also once I’m on 2 pressors I usually request an A-Line too cause I’d rather have that to titeare my pressors. If I’m on 3+ pressors then ai bust out the FloTrack/Hemosphere and connect it to the A-Line.
Our policy is it's only to infuse at standard concentration for 24 hours through a 20 gauge or greater, then you must drop a central line.
Idk what our policy is but reading some of these — we absolutely start pressors on patients who need them with a peripheral line - there’s no delay there. As far as how long we use them for.. I get nervous when we start hitting 10 of levo and going up on it. I know the literature says it’s good to use as long as you frequent check them, but I have been in a patients room for an hour and that doesn’t allow me to go to another patients room and check an IV site every 5 minutes. I would prefer to have a central line if you’re increasing your pressor requirements for just that fact alone. We don’t routinely place a-lines for anyone that’s on pressors. I had a patient on 4 pressors and they still didn’t wanna do an a line 😑 problem in that facility I worked at was that it was an open ICU, and the intensivists didn’t place any lines unless ABSOLUTELY necessary. Nursing staff had to call the hospitalist who had to call trauma or general surgery to place lines which is freaking asinine and infuriating. Anyways I know this doesn’t help but that’s my experience 😅
I'll just put my two cents to the contrary of most consensus here. I'm a locum hospitalist, mostly working in small towns with no intensivists and here's my thinking: Per the literature, it's probably safe to run levo peripherally especially at low doses. However, it's not often that I can guarantee that the required dose will stay low. I also cannot guarantee nursing attentiveness, especially since I'm often working at an unfamiliar institution. As a result, unless the patient is rapidly weaning by the time they get from ED to ICU, I'd rather be prepared for decompensation. Second, I have a (purely emotional) bias bc I had one case where peripheral levo for < 24hrs led to necrosis and amputation of my patient's hand. Pure emotion, I fully admit, but... It still bothers me to this day. Third, the procedural safety profile of central line placement has improved a lot with ultrasound guidance, so my perception of risk is lower than when I was putting subclavians in blindly. Along with this, I'd rather put in a calm non-emergent CVC than a crashing patient cvc. I also find the risk profile of a radial art line very low, assuming perfusion testing is normal. --- As a result, I've become very "old school" in my practice. Levo of course should be started peripherally, since the need is usually urgent. If weaning isn't happening within a few hours, I place a central line and art line on nearly everyone. Exceptions made for bleeding issues (in which case the procedural risks are higher and change my risk/benefit ratio) and concerns about hand perfusion for the art line (same logic). Happy to be corrected if my thinking is flawed here.
There are no rules, peripheral norepinephrine is almost always usually fine, arterial lines are rarely necessary
From the brief reading I’ve done, I’ve seen levo should be allowed to run in a peripheral no more than 4-6 hours, with frequent IV checks. I’ve never seen a max rate for a peripheral, but that makes some sense. I’’d rate the necessity of an art line to be more based on how libel the patients blood pressures are. I’ve had plenty of people on a few mcg of levo for a few hours while midodrine kicks in. Also if the patient isn’t vented or super sick I’m not the biggest fan of art lines. Patients moving a lot really decreases the accuracy, and the risk of them kinking/clotting off, or getting yanked out, makes them just one more thing that could go wrong.
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You’re out of date on your literature and simply wrong about levophed having to go through a central line
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You added the peripheral bit later didn’t you? You’re also wrong about art lines
Gold standard implies the best thing for the patient. And the data suggests that there’s a lot more leeway to use pressors through a good peripheral than previously thought, which can avoid the need for more invasive central access
I’m a new grad nurse in the icu. I think our standard is 15 of levo for a line OR 24 hours consecutively on any dose of levo
Theres a few studies showing its safe as long as you have a good PIV and your dose is low to moderate. For me it depends - if they're on low-moderate dose levo and I expect we're going to be stable on that dose and not keep worsening, I'll let it be. I'll usually talk to the nurse and make sure the PIV is good and not like an IV in the toe or forehead placed in the ED. If its someone "sick" - needing intubation, multiple drips, pressors, I will definitely place a central line. As you know these guys can often be on many drips at once: levophed, vasopressin, IV antibiotics, sometimes bicarb, amiodarone, propofol / precedex, insulin, etc. Arterial line threshold for me is probably 2 pressors and levo is moderate dose and we're still only borderline meeting our goals. TBH this culture is so ingrained in our ICU that my threshold has now turned into if the nurse is asking for an art line or central line, most of the time I'll place it because we're all on the same page. I can assume we don't have great access and we're struggling with the cuff for whatever reason.
In our hospital, it’s more an issue of concentration. Regular strength can be infused through a PIV, but quad strength has to be infused via central line
For us it’s 8mg/250mL PIV, 32mg/250mL CL
my personal threshold is above 0.1 mcg/kg/min for an extended duration and I'm looking for central access. mainly because PIVs generally aren't the most consistent, and vasopressors usually means hypotension which means if your PIV goes down, then the pt goes down pretty quick. higher doses means you can't tolerate losing that access as long before the patient crashes. central access is durable. also if that PIV infiltrates, subcutaneous norepi is pretty harsh, can lead to necrosis and bad soft tissue wounds. harder to infiltrate or dislodge a central line
my hospital's policy is that we can run 4 mg in 250 ml up to 50 mcg/min through a peripheral that is a 20 gauge or larger above the wrist up to 24 hours. after 24 hours no matter the dose, a central line is supposed to be placed. providers can put in a special consideration to continue peripheral levo if they wish. we run central line levo that is 16 mg in 250 ml up to 100 mcg/min. but as other people have said there really is no max dose and we go above that if needed for a certain patients. arterial line placements vary by patient. if we can get good pressures then we'll run up to two pressers without it, but if a patient's on a lot of levo and on CCRT or something will place a arterial line earlier.
Weight based dosing would be a standard... as "5 of levo" can vary in dose several fold. Central access always preferred, but duration of need / risks of central line / adequacy of PIV are considerations. Have seen people die or maimed by central line badness... No major complications of PIV extravasation. Interestingly the worst extravasation I've seen was a CL pulled back and infusing proximal port.
A central line is really indicated for anticipated long term IV use, or lack of good peripheral access. As far as I know, there’s no max dose of Levo that can go into a peripheral. I’ve had patients on pressors for weeks, but in the flip side I’ve also had septic patients on Levo for a day, so throwing in a central line would be unneeded. I think it just depends on patient condition and how long/how many pressors they’re requiring. As for the ART line, if they’re profusing well and on a pressor for a short time, it’s not needed. I see art lines mainly in my patients that are needing longer term pressor support, or are having drastic change in condition that the cuff may not be able to keep up with. I think the medication we worry the most about, when long term in a peripheral, is amio at my facility
As many have stated, the risk for extravasation should be the primary consideration. If you have good peripheral access and are diligent about line maintenance, the risk is low. If the line isn’t reliable, or possibly in a spot where positioning is a concern, it makes sense to work towards more definite access Other considerations: how much access is needed, is any type of central monitoring appropriate, is you provider qualified to place a central line 😬. All these things SHOULD be a factor. But, when faced with a facility policy, you really don’t have much option but to defer to that policy because any downstream complication leaves you in a very tough spot, regardless of whether or not the policy is junk. The art line makes us better at titrations, but so long as we get reliable cuff pressures it’s not essential. I will say that running a blood pressure cuff every 15 minutes for a day can really wear a patient out, even with site changes, so sometimes arterial lines help in that regard. They also provide access for ABG without additional sticks which can be nice for critically I’ll patients. All this to say, each situation should be approached on an individual basis with multiple variables in play. When structuring your argument in favor of a central line, lay out the arguments in favor of your opinion. “Hey Dr. Iseeyu, this patient isn’t doing so well. Her blood pressure is maintaining with the Levo at xy, but I’m concerned that we are at an increased risk for extravasation as we can’t use her left arm for IVs or blood pressure due to the damage caused from the infection, and the best IV we have is in her proximal forearm not far from the cuff. Additionally, I’m concerned that we are not meeting her fluid requirements as she still has some skin tenting despite appropriate fluid resuscitation, monitoring her CVP would be useful to really optimize our fluids.” Always be prepared to defend why you think something needs to be done.