Can norepinephrine (vasopressor) be administered via a peripheral line?

Norepinephrine Administration via Peripheral Line

Norepinephrine can be safely administered through a peripheral venous line as a temporary measure when central venous access is unavailable or delayed, provided proper protocols are followed to minimize extravasation risk. 1

Evidence for Peripheral Administration

• Current guidelines acknowledge the safety of peripheral norepinephrine administration when following specific protocols, with the American Heart Association stating that if central access is unavailable or delayed, peripheral IV administration can be used temporarily 1
• Recent research shows low rates of extravasation (2.3-4.5%) when peripheral norepinephrine is administered according to institutional protocols, with minimal to no tissue injury in most cases 2, 3
• A 2024 prospective observational study of 635 patients demonstrated that peripheral norepinephrine administration could avoid central line placement in 51.6% of patients, with no cases requiring surgical intervention for extravasation 4

Recommended Protocol for Peripheral Administration

• Use a large peripheral vein, preferably in the antecubital fossa or upper arm, avoiding veins of the leg, particularly in elderly patients or those with occlusive vascular diseases 5, 2
• Select a 16-20 gauge catheter for administration to ensure adequate flow 6
• Limit peripheral administration to a maximum of 24 hours 6, 7
• Implement regular monitoring with visual inspection of the IV site every 2 hours 7
• Consider using the lowest effective concentration and dose to minimize risk 1

Precautions and Monitoring

• Monitor for signs of extravasation including blanching along the course of the infused vein 5
• If extravasation occurs, phentolamine (0.1-0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) should be injected intradermally at the site to counteract dermal vasoconstriction 1
• Continuously monitor blood pressure every 2 minutes from the time administration is started until the desired blood pressure is obtained, then every 5 minutes if administration is to be continued 5
• Watch the rate of flow constantly, and never leave the patient unattended while receiving norepinephrine 5

Transition to Central Access

• While peripheral administration is acceptable temporarily, central venous access should be established as soon as feasible for prolonged vasopressor therapy 1
• Central venous access is preferred for administration of norepinephrine to minimize risk of extravasation 1
• Consider transitioning to central access if:
  • Peripheral administration exceeds 24 hours 6, 7
  • Higher doses are required 1
  • Signs of peripheral infiltration or ischemia develop 5

Special Considerations

• Avoid veins in the leg, particularly in elderly patients or those with occlusive vascular diseases (atherosclerosis, arteriosclerosis, diabetic endarteritis, Buerger's disease) as these conditions are more likely to occur in the lower extremity 5
• A catheter tie-in technique should be avoided if possible, as obstruction to blood flow around the tubing may cause stasis and increased local concentration of the drug 5
• Adrenergic drugs should not be mixed with sodium bicarbonate or other alkaline solutions in the IV line, as they are inactivated in alkaline solutions 1

By following these guidelines, norepinephrine can be safely administered through a peripheral line when necessary, potentially avoiding delays in treatment while central access is being established.