Peripheral Vasopressor Protocol Deviations Rarely Led to Extravasation

Key Takeaways

• In more than 3,500 hospitalized adults treated across 10 hospitals in one academic health system, electronically suspected peripheral vasopressor protocol deviations were not always confirmed on chart review.
• Confirmed deviations were most often dose-related and usually arose when shock worsened before central access was available.
• Within the confirmed-deviation group, 10/73 patients (13.7%) had reported extravasation, and 3/73 (4.1%) required phentolamine treatment.
• In the full cohort, most phentolamine-treated extravasations occurred during protocol-concordant peripheral vasopressor use.

When shock worsens before central venous access is available, clinicians may start vasopressors through a peripheral line to avoid delaying hemodynamic support. That decision can conflict with institutional limits on dose, duration, and agent selection when bedside conditions are changing quickly and access plans are still in flux. To characterize how that tension played out in routine care, investigators reviewed peripheral vasopressor use across one academic health system.

Investigators conducted the Critical Care Explorations analysis of peripheral vasopressor protocol deviations as a retrospective observational study of electronic medical records across 10 hospitals in one academic health system from October 2020 through May 2023, after the institutional protocol had been implemented in October 2020. Admitted adults who received any peripheral vasopressor infusion were eligible. The protocol limited peripheral use to a single vasopressor for up to 24 hours and excluded peripheral vasopressin. Investigators identified 3,518 patients who received peripheral vasopressors, electronically flagged 1,258 for possible deviation, manually reviewed a weighted random sample of 162 charts representing 12.8% of suspected cases, and confirmed 73 deviations. They also captured all phentolamine-treated extravasation events in the full source population regardless of protocol concordance, excluding prehospital, operating-room, and bolus-associated events.

Among the 73 patients with confirmed deviations, exceeding the maximum allowed dose was the dominant pattern at 63/73 (86.3%). Most confirmed deviations occurred during worsening shock while placement of a central venous catheter (CVC) was still pending, accounting for 58/73 cases (79.4%), and 56/73 patients (76.7%) subsequently required a CVC for ongoing support. Other departures from protocol, including simultaneous peripheral vasopressors, infusions beyond the time limit, and peripheral vasopressin use, were less common and sometimes overlapped within the same patient.

Reported extravasation occurred in 10/73 patients (13.7%) with confirmed deviations, and 3/73 (4.1%) required phentolamine. In the full-cohort phentolamine-treated extravasation analysis, 47/3518 patients (1.3%) received phentolamine for extravasation, and 72.4% of those treated events occurred during protocol-concordant use. When infiltration grade was documented, the study reported that most events were grade 2 or lower.

The authors noted that interpretation is limited by the retrospective, single-health-system design, reliance on nursing documentation, a small manually reviewed sample for confirmed deviations, and nonstandardized extravasation documentation. They also emphasized that the confirmed-deviation cohort was intentionally enriched for higher-risk exposures, so those event rates should not be treated as direct estimates for all peripheral vasopressor use. The discussion further suggested that some deviations reflected operational ambiguity, including how to classify intermittent low-dose infusions or whether changing to a different peripheral intravenous catheter reset the 24-hour limit.

The authors concluded that deviations from the institutional protocol were mainly dose-related and tended to occur as shock worsened while central access was still pending. In this health-system experience, they also reported that clinically significant extravasation remained uncommon and that bedside escalation, rather than a single recurring misuse pattern, accounted for much of the observed divergence from protocol.

Clinician Questions

How were peripheral vasopressor protocol deviations confirmed across the 10-hospital health system?

Investigators first identified admitted adults who received peripheral vasopressors through electronic medical record and pharmacy-dispensing data, electronically flagged possible protocol deviations, and then used manual chart abstraction on a weighted random sample of suspected cases to determine whether a true deviation had occurred and why it happened.

What counted as a peripheral vasopressor protocol deviation in this health-system study?

A protocol deviation meant exceeding dose limits, exceeding the 24-hour duration limit, running more than one peripheral vasopressor at the same time, or administering vasopressin peripherally within a protocol that limited peripheral use to a single vasopressor for up to 24 hours and excluded peripheral vasopressin.

Why did the authors say many peripheral vasopressor deviations occurred during shock care?

The authors attributed many confirmed deviations to worsening shock while central access was still pending, and they noted that bedside ambiguity around intermittent low-dose vasopressor use and whether moving to a different peripheral intravenous catheter reset the protocol clock also contributed in some cases.