Introduction:
Vascular access is an essential intervention in the pediatric intensive care unit. It is required for the administration of drugs, such as vasoactive drugs, nutritional supplements, intravenous (IV) fluids, and blood products. Vascular access is usually obtained by central venous line (CVL), peripheral intravenous cannulation, peripherally inserted central line, or intraosseous access, depending on the availability of the resource and emergency of the condition. In kids, peripheral venous access for resuscitation is cost-effective and requires minimal expertise. However, it has its share of complications, such as extravasation, inability to deliver high osmolality fluids, a limited drug delivery rate, and difficulty establishing during a shocking state. Central venous line is promising in its mode of drug delivery.
What Is Shock?
Shock is a critical life-threatening condition that is characterized by an abrupt drop in blood flow throughout the body. Blood loss, severe stress or trauma, heatstroke, severe infection, an allergic reaction, poisoning, severe burns, and several other causes can cause shock. When a person is in shock, the organs do not get enough nutrients and oxygen for proper functioning. If not treated promptly, this can lead to permanent organ damage or even death.
What Are the Signs and Symptoms of Shock?
The symptoms of shock include
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Bluish lips and fingernails.
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Anxiety.
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Confusion.
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Chest pain.
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Rapid pulse.
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Increased breathing.
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Weakness.
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Enlarged pupils.
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Dizziness.
What Are Vasoactive Agents and How Do They Work?
Vasoactive agents are the drugs that cause the blood vessels to constrict (narrower) or dilate (wider), thus increasing or decreasing blood pressure or heart rate. The clinical use of vasoactive drugs improves systemic hemodynamics and decreases organ perfusion and oxygenation disturbances during shock. Adrenaline, Noradrenaline, Dopamine, and Dobutamine are some examples of vasoactive agents. In the pediatric population, vasoactive agents are infused through the central line. However, their use in the peripheral lines has only been approved for emergencies. The peripheral infusion of vasoactive agents is safe in places with poor resources.
Vasoactive agents are administered via central veins with proper hemodynamic monitoring. Central venous catheters (CVC) are expensive and need the expertise to insert. Careful monitoring of the lines is required to prevent any blood infection. Peripheral venous access is used in places with inadequate cost and a lack of adequate nursing staff for the routine use of central venous access in the pediatric intensive care units (PICU). The number of children needing inotrope (drugs that change the force of muscle contraction) infusions exceeds the availability of CVCs. Hence inotropes are administered through peripheral veins in most pediatric intensive care units (PICU) and emergency departments in most developing countries. Invasive hemodynamic monitoring is used for only a few critically ill children. It is recommended that only central venous access should be administered except in the emergency department. The leakage of the vasoactive agents can cause severe local reactions and tissue necrosis. This is the main concern for the use of peripheral veins for administering vasoactive agents. According to the American College of Critical Care Medicine guidelines, if central access is likely to delay the infusion of an inotrope, then it can be infused in a peripheral line with monitoring.
Why Is Peripheral Venous Line Preferred?
For vasoactive therapy, central venous access is the preferred choice. However, the administration of vasoactive medications with a diluted concentration through the most proximal peripheral intravenous access or an intraosseous cannula is allowed during the initial resuscitation period. Central venous access has been associated with a low risk of adverse events. The access site is closely monitored for patency during peripheral venous administration of vasoactive medications. Data from several studies suggest that infrequent side effects are encountered when vasoactive therapy is started and temporarily administered through peripheral IV access compared to central access. The most common peripheral venous line sites are the forearm and antecubital fossa, with the incidence rate of extravasation being four percent.
Extravasation is the leakage of the vasoactive solution from its vascular pathway (vein) into the surrounding tissues. Infiltration is the leakage of a non-vasoactive solution from the vein into the surrounding tissue. Extravasation injury is a serious complication in the intensive care unit. Children are more prone to extravasation injury due to the small size of the veins and capillary leakage. Inotropes are one of the common drugs in extravasation injury. Extravasation injuries can be classified into four stages.
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Stage I Injury - There is pain at the site, with no swelling, blistering or hard areas. The skin is normal, discolored, and warm with intact integrity.
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Stage 2 Injury - There is pain with mild swelling and leakage around the site, no blisters, and hard areas with redness or discoloration.
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Stage 3 Injury - There is pain at the site, moderate swelling with leakage around the site, blistering with hard areas, blanching of skin and purple or black discoloration, and skin cool to touch with altered integrity.
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Stage 4 Injury - This is a medical emergency with or without pain.
What Are the Risk Factors of Peripheral Venous Line?
The risk factors for the side effects in kids receiving vasoactive therapy through peripheral access include the following:
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Young age (lesser than one-year-old).
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Small gauge IV (such as 24 gauge).
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Intravenous site in hand.
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Increased severity of illness.
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Longer duration (more than three to six hours) of peripheral infusion.
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Higher doses of vasoactive medications.
If the patients without the risk factors for peripheral vasoactive complications show less severity of the condition and are thought to wean off the vasoactive medications within six hours. In that case, a central venous catheter placement can be avoided.
Conclusion:
Vasoactive drugs are ideally infused through a central line; however, in an environment with poor resources, the use of vasoactive agents through a peripheral line in children with shock is recommended as it is found to be safe without serious adverse effects if proper nursing care is provided. It is also cost-effective. An overall incidence of extravasation events was found in certain kids receiving vasopressors through a peripheral venous route. There are many reasons to decide against using a central venous line, such as patient preference, fear of complications, or anticipated short duration of use.
Moreover, the administration requirement of vasopressor therapy, once thought to be an absolute indication for a central venous line, may be more of a relative indication. Future research should be carried out, and the patients should be informed about the risk of the peripheral administration of vasopressors.
