Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI.
Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI; The Michigan Hospital Medicine Safety Consortium Coordinating Center, Ann Arbor, MI.
Chest. 2024 Apr;165(4):847-857. doi: 10.1016/j.chest.2023.10.027. Epub 2023 Oct 26.
Vasopressors traditionally are administered via central access, but newer data suggest that peripheral administration may be safe and may avoid delays and complications associated with central line placement.
How commonly are vasopressors initiated through peripheral IV lines in routine practice? Is vasopressor initiation route associated with in-hospital mortality?
This retrospective cohort study included adults hospitalized with sepsis (November 2020-September 2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement.
Five hundred ninety-four patients received vasopressors within 6 h of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594 [67.3%]). Patients with peripheral vs central initiation were similar; BMI was the only patient factor associated independently with initiation route (adjusted OR [aOR] of peripheral initiation [per 1-kg/m increase], 0.98; 95% CI, 0.97-1.00; P = .015). The specific hospital showed a large impact on initiation route (median OR, 2.19; 95% CI, 1.31-3.07). Compared with central initiation, peripheral initiation was faster (median, 2.5 h vs 2.7 h from hospital arrival; P = .002), but was associated with less initial norepinephrine use (84.3% vs 96.8%; P = .001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%; aOR, 0.66; 95% CI, 0.39-1.12). No tissue injury from peripheral vasopressors was documented. Of patients with peripheral initiation, 135 of 400 patients (33.8%) never received a central line.
Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, the findings of wide practice variation that was not explained by patient case mix and lower use of first-line norepinephrine with peripheral administration suggest that additional standardization may be needed.
血管加压素传统上通过中央通路给药，但新数据表明外周给药可能是安全的，并且可以避免与中央置管相关的延迟和并发症。
在常规实践中，有多少血管加压素是通过外周静脉内途径开始使用的？血管加压素起始途径与院内死亡率是否相关？
这项回顾性队列研究纳入了 2020 年 11 月至 2022 年 9 月在密歇根医院医学安全联盟（由密歇根蓝十字蓝盾赞助的合作质量倡议）旗下的 29 家医院住院的脓毒症患者。我们评估了早期血管加压素起始途径、与外周起始相关的因素和结局，以及中心静脉置管的时间。
594 名患者在入院后 6 小时内接受了血管加压素治疗，纳入了本研究。外周血管加压素起始是常见的（400/594 [67.3%]）。与中央起始相比，外周起始的患者相似；BMI 是唯一与起始途径独立相关的患者因素（外周起始的调整后比值比[OR]，0.98；95%CI，0.97-1.00；P=0.015）。具体医院对起始途径有很大影响（中位数 OR，2.19；95%CI，1.31-3.07）。与中央起始相比，外周起始更快（中位时间，从入院到起始分别为 2.5 小时和 2.7 小时；P=0.002），但初始去甲肾上腺素使用率较低（84.3% vs 96.8%；P=0.001）。我们没有发现起始途径与院内死亡率之间的独立关联（32.3% vs 42.2%；OR，0.66；95%CI，0.39-1.12）。没有记录到外周血管加压素引起的组织损伤。在接受外周起始的 400 名患者中，有 135 名患者（33.8%）从未接受过中心静脉置管。
在密歇根州的各家医院中，外周血管加压素起始是常见的，具有实际益处，包括加快血管加压素的给药速度，并避免三分之一患者进行中心静脉置管。然而，发现实践差异很大，无法用患者的病例组合来解释，并且外周给药时第一选择的去甲肾上腺素使用率较低，这表明可能需要进一步的标准化。
