First Author: Zachary Jerusalem, MD – Cleveland Clinic Foundation Co-Author: Astha Guliani, Resident Co-Author: Ahmed Abushamma, MD – MD, Cleveland Clinic Akron General Co-Author: Ali Ejaz, MD – Resident, Cleveland Clinic Akron General Co-Author: Fatima Abdulle, MD – Resident Physician, Cleveland Clinic - Akron General
Introduction: Central venous catheters (CVCs) are commonly used for vasopressor delivery but pose risks like infections, thrombosis, and mechanical issues. Peripheral norepinephrine (PNE) offers a safer alternative, though extravasation remains a concern. While PNE’s safety is established in tertiary centers, data from community ICUs are limited. This quality improvement project assessed PNE’s safety, feasibility, and its effect on reducing CVC use in a community ICU setting.
Methods: We conducted a retrospective review of ICU patients receiving PNE per protocol. Exclusions applied to cases with incorrect vasopressor orders or care in units lacking trained staff (e.g., ED pre-expansion). Collected data encompassed patient demographics, PNE duration, frequency and reasons for CVC placement, peripheral IV (PIV) characteristics, compliance with documentation protocols, and PIV-related complications. AI-assisted editing of this abstract was used.
Results: Among 300 ICU patients studied (50.7% male; 87.0% White), septic shock predominated as the indication for vasopressor use (56.2%), with the majority (69.3%) treated in the medical ICU. The mean ICU length of stay was 291 hours. PNE was administered in 297 patients, with an average infusion duration of 61.2 hours (range 0.07 to 513.1 hours). Only 29.9% required escalation to CVC placement, predominantly due to increased vasopressor requirements (79.1%), with a median time to central line insertion of 18.4 hours post-PNE initiation. Two appropriate peripheral IVs were present in 84.2% of cases, most frequently located in the forearms. Ultrasound guidance was utilized for initial and secondary PIV placements in 61.7% and 49.5% of patients, respectively. Extravasation events were rare, occurring in 1.4% of patients; all cases were promptly treated with antidotes. Compliance with protocol-mandated 2-hour patency and phlebitis assessment was low at 36%. Among PIVs used >24 hours, only 9.3% were rotated and 9.2% had confirmed blood return.
Conclusions: PNE showed strong safety with low extravasation and less CVC use, cutting central line risks and enabling faster vasopressor delivery. Improved documentation post-training led to expansion into ED and NSICU. Planned PDSA cycles will boost monitoring through focused ultrasound and documentation training.
