(1664) Hold the Line: Instituting a Protocol for Peripheral Norepinephrine in a Community ICU

Introduction: Vasopressors are commonly thought to require delivery through central venous catheters (CVCs), which have complications (mechanical issues, infections, VTE/stenosis). Peripheral norepinephrine (PNE) has been shown to be generally safe, with the most concerning complication being extravasation and resulting skin/soft tissue injury. Few studies show implementation of PNE into a community ICU setting. This QI assesses safety and feasibility of initiating peripheral norepinephrine (PNE) in critically ill patients and whether PNE can reduce the number of CVCs placed.

Methods: All eligible patients were chart reviewed to assess documentation compliance and adverse outcomes of infiltrated peripheral IVs (PIVs). All patients in the hospital meeting criteria were included. Exclusion criteria included use of the incorrect orderset by the ordering provider, or not being in a participating location where staff were trained in this protocol (e.g. ED).

Results: Patients were audited for this QI project over 12 months. Data analysis reveals adequate documentation compliance in qualifying PIV locations, gauges, US confirmation, line patency and infiltration status, and dose of PNE. Additionally, PNE was generally well tolerated by patients in this protocol. After being started on PNE, the majority of patients did not require CVC placement within their hospital stay.

Conclusions: Based on these data with minimal complications of PNE, and significant delay in or prevention of CVCs thereby reducing complication risks or need for urgent CVC placement, this protocol is working on being expanded to the ED and neuro ICU settings in our hospital. Educational debriefings were held with ICU nursing staff/managers, LIPs, and pharmacists. Documentation compliance then increased from 47% to 83%. A study with the same protocol in a larger M-ICU showed extravasation in 5.5% of patients (none with severe tissue injury), so more data collection is warranted. PNE has demonstrated safety, efficacy, and reduces complications associated with CVCs. This protocol was well-adopted by our hospital staff and well tolerated by patients.