Bibliographic information
Guideline—
Year of Publication—
Issuing Institution—
Recommendation
New
WHO suggests that for patients with suspected or confirmed filovirus disease requiring initiation of vasopressors, peripheral intravenous catheters be used rather than central venous catheters.
Recommended in favor
Conditional
Certainty of evidence
Very low
Notes and Remarks
- This recommendation applies to children and adults, including pregnant women. • Peripheral intravenous administration avoids the delay associated with central venous catheterization and enables more timely treatment which may improve outcomes. • Use the largest bore peripheral intravenous catheter possible to minimize the risk of extravasation. • Systematic and frequent monitoring of intravenous site is required. • Transition to the use of central venous administration should be anticipated. Practical info Managing a vasopressor such as norepinephrine through a peripheral line requires strict adherence to safety protocols to prevent tissue necrosis.
- 1.Pre-administration requirements
- Use a large-bore intravenous cannula. The preferred site is a large vein in the forearm – be careful of antecubital lines which can occlude if the elbow is flexed.
- Check patency: confirm brisk blood return and flush the line with 10 mL of 0.9% sodium chloride to ensure no resistance or swelling.
- Use a standard 4 mg in 250 mL concentration. Higher concentrations increase the risk of severe injury if extravasation occurs.
- 2.Initiation and titration
- Use a dedicated infusion pump.
- Pump settings and concentration should be verified by two clinical staff.
- Record blood pressure and heart rate immediately prior to starting.
- 3.Monitoring
- To detect extravasation early, monitoring must be frequent and documented. Check the administration site every 30 minutes, including visual inspection and palpation of the site for coolness, blanching or oedema.
- Monitor physiological parameters according to standard operating procedures.
- Warning signs: if the patient complains of pain, burning, or if the skin appears pale/cold at the site, stop the infusion immediately.
- 4.Management of extravasation
- Leak into the subcutaneous tissue can causes intense local vasoconstriction, leading to ischaemia and necrosis.
- Immediately:
- Stop the infusion: do not remove the intravenous catheter immediately.
- Aspirate: attempt to aspirate as much residual drug as possible through the existing cannula.
- Notify: alert the clinical team. • Administer phentolamine
- Phentolamine is an alpha-adrenergic antagonist that reverses the vasoconstriction.
- Dose: 0.1–0.2 mg/kg, maximum 10 mg.
- Dilute in 0.9% sodium chloride to 10 mL volume.
- Inject the solution into the extravasated area using the existing cannula, and infiltrating into the soft tissue using a fine-gauge needle (25G or 27G).
- Remove the cannula.
- Consider how to administer the vasopressor through another site, and beware hypotension related to the phentolamine and the pause in vasoactive medication.
- Document the leak and the action you took in the patient notes.