Charbel Ramy C, Ollier Vincent, Julliand Sebastien, Jourdain Gilles, Lode Noëlla, Tissieres Pierre, Morin Luc
Pediatric Intensive Care Unit DMU 3 Santé de l'enfant et de l'adolescent AP-HP Paris Saclay University - Bicetre hospital Le Kremlin-Bicêtre France.
Division of Pediatric and Neonatal Critical Care and Transportation AP-HP Paris Saclay University - Antoine Beclère hospital Clamart France.
J Am Coll Emerg Physicians Open. 2021 Mar 2;2(2):e12395. doi: 10.1002/emp2.12395. eCollection 2021 Apr.
In prehospital and emergency settings, vasoactive medications may need to be started through a peripheral intravenous catheter. Fear of extravasation and skin injury, with norepinephrine specifically, may prevent or delay peripheral vasopressor initiation, though studies from adults suggest the actual risk is low. We sought to study the risk of extravasation and skin injury with peripheral administration of norepinephrine in children in the prehospital setting.
We performed a retrospective study of pediatric patients (≤18 years) who received a vasopressor during prehospital transport. We collected data from retrieval and hospital records from 2 pediatric medical retrieval teams in the Paris/Ile-de-France region. Patients were eligible if they had documentation of distributive or obstructive shock and administration of norepinephrine through a peripheral catheter (intravenous or intraosseous) during retrieval. The primary outcomes were the occurrence of extravasation and evidence of skin injury. We also examined approach to norepinephrine administration (concentration, duration, proximal vs distal site) and hospital outcomes.
Over a 3-year-period, 37 pediatric patients received norepinephrine through a peripheral catheter (33 intravenous, 4 intraosseous). Median patient age was 1.8 years. Thirty-two patients (86.5%) had septic shock. The median total duration of norepinephrine infusion was almost 4 hours. One patient (2.7%, 95% confidence interval 0.5%, 13.8%) had suspected extravasation from a 24-gauge intravenous catheter in the hand, with local skin hypoperfusion. Skin changes were noted after 135 minutes of norepinephrine infusion. Perfusion normalized after catheter removal, and there were no other sequelae.
In a 3-year sample of pediatric patients from a large metropolitan area, we found only 1 patient with evidence of any harm with peripheral administration of norepinephrine. This finding is consistent with the adult literature but requires multicenter and multiyear investigation before a firm recommendation for this practice can be made.
在院前和急诊环境中，血管活性药物可能需要通过外周静脉导管给药。特别是对去甲肾上腺素外渗和皮肤损伤的担忧，可能会阻止或延迟外周血管升压药的使用，尽管来自成人的研究表明实际风险较低。我们试图研究院前环境中儿童外周给予去甲肾上腺素时发生外渗和皮肤损伤的风险。
我们对在院前转运期间接受血管升压药治疗的儿科患者（≤18岁）进行了一项回顾性研究。我们从巴黎/法兰西岛地区的2个儿科医疗救援团队的检索和医院记录中收集数据。如果患者有分布性或梗阻性休克的记录，以及在检索期间通过外周导管（静脉或骨内）给予去甲肾上腺素的记录，则符合入选标准。主要结局是外渗的发生和皮肤损伤的证据。我们还检查了去甲肾上腺素的给药方法（浓度、持续时间、近端与远端部位）和医院结局。
在3年期间，37例儿科患者通过外周导管接受了去甲肾上腺素治疗（33例静脉给药，4例骨内给药）。患者中位年龄为1.8岁。32例患者（86.5%）患有感染性休克。去甲肾上腺素输注的中位总时长近4小时。1例患者（2.7%，95%置信区间0.5%，13.8%）手部24号静脉导管疑似发生外渗，伴有局部皮肤灌注不足。去甲肾上腺素输注135分钟后出现皮肤变化。拔除导管后灌注恢复正常，且无其他后遗症。
在一个来自大城市地区的3年儿科患者样本中，我们发现仅有1例患者在外周给予去甲肾上腺素时出现任何损伤的证据。这一发现与成人文献一致，但在能够对此做法做出确凿推荐之前，还需要进行多中心、多年的研究。
