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PODCAST: Pushing Pressors in the Periphery

The mantra of the Broome Docs site is “bringing great care, out there.”  And today’s topic goes right to the heart of that theme.  It is one of my pet topics – so apologies in advance if the rant is too long or detailed.

This is a discussion about the early management of septic patients.  I live and work in an area where this is a common and deadly problem.  Care is far from the idealised ICU practice.  However in recent times the playing field has been levelled by new data that suggests that maybe a simpler approach can deliver good outcomes.  So this is my attempt to deal with a wicked problem – remote resuscitation of the shocked septic patient.

Although I am talking about how I think we can do it well in remote areas, I imagine some of this discussion is just as relevant in a big city ED.  Specifically this is an attempt to make a case for the early and liberal use of vasopressors [particularly noradrenaline] in patients with septic shock.

There has been a huge amount of evidence published and paradigms shifted in the last 12 months when it comes to the early management of sepsis.  EDGT is out.  What is in?   Well –  solid, careful and timely delivery of the basics of:

  1. resuscitation,
  2. early appropriate antibiotics with
  3. aggressive source identification and control.

It has been famously stated that in the  post-EGDT era: it doesn’t matter what “shit” you give, as long as you “give a shit”.  The substantial improvements in patient outcomes over the last 12 years have come about probably as the result of clinicians being more aware of the urgency of care and being proactive in their management.   We have also likely reduced the rate of iatrogenesis in that time period.

So this discussion focuses on the first part of that triad of early care for the septic patient: RESUSCITATION.  In most small hospitals the resuscitation basically includes IV fluids and after that has failed some sort of vasopressor.  Here in rural Australia there are really only 2 commonly used ‘pressors’ – metaraminol [darling of the bush anaesthetist] and noradrenaline [norepi for my N. American readers!].  Now I know that some will argue that Norad is not just a vasopressor, and that is true.  However, at the doses it is commonly used its main effect is on the venous circulation.  So humour me!

OK – so here we go.  I am going to try and convince you that we ought to be using:

  1. Noradrenaline
  2. through a peripheral cannula (initially)
  3. early in the Resus phase
  4. in a concomitant or synergistic manner with judicious fluids

Now I realise that there are several controversial / new ideas in that list.  So have a listen to the podcast as I try to make a case for using this newish, some may say aggressive, strategy in the early management of septic patients.  I am specifically referring to patients whom are being cared for in low-resource centres – places without 24 hour cover, no Crit Care facility or ICU trained Docs.  That maybe in the middle of the Kimberley – or it could be in your local hospital between the hours of midnight and six AM!

Have a listen.HERE

Casey

REFERENCES:

Dr John Myburgh’s excellent discussion of “FLUIDS: 2015” on the ICN Podcast is here

Dr Paul Marik’s recent dissection of : “the demise of EGDT” [from Acta Anaesthesilogica Scandinavia ]

the NEJMs trilogy of the:

Dr Bai et al Early versus delayed administration of norepinephrine in patients with septic shock.  From Critical Care Oct 2014

Ricard’s RCT of central vs peripheral catheters in ICU

Loubani & Green systematic review of peripheral vs. central vasopressors Journ of Crit Care June 2015.

Weingart: Podcast 107 – Peripheral Vasopressor Infusions and Extravasation

Comments

  1. Nice post Casey – we share the passion for timely recognition and treatment of insidious sepsis in rural hospitals

    In SA very few of us have noradrenaline – we’re trusted with adrenaline, ephedrine and metaraminol only as available pressors

    So I usually have to run an adrenaline cordial initially (1mg in a litre, 1 mcg per ml) then get central access and run std strength adrenaline

    Should we have norad?

    • Yes Tim
      You should have NORAD in your kit
      Works! Cheap! Evidence to support, arguably standard of care
      Myburgh has stated Adrenaline is good. But, not the majority practice in my world
      C

  2. Yup, I hear you mate – the decision will lie with CountryHealthSA who order the drugs!

  3. Dean Burns says

    Hi Casey

    I’m at the beginning of writing a policy/protocol for our hospital and wanted to ask you if you’d be prepared to share the WA protocol for peripheral noradrenaline you use?

    I’m also interested in the dilution of the noradrenaline. I’m the UK, we’d typically use an 80mcg/mL dilution in the ED & 160mcg/mL in ICU. Do you dilute the mixture further for peripheral use or does the change in concentration cause confusion/increase the risk of drug errors?

    • Hi Dean
      The doses we use are 4mg in 500ml of 5% dextrose
      RFDS guidelines here: https://www.flyingdoctor.org.au/assets/magazine/file/Part_2_-_Drug_Infusion_Guidelines_-January_2016_-_Version_7_2.pdf
      (page 36).
      We use 4mg in 50 Ml once central access is achieved/used. So the concentration / rates are 10x for ease of multiplication.

      i will email you the protocol I wrote for WA HEalth – it is pretty straightforward.
      Casey

      • PETER VALENTINE says

        Hi Casey,
        I have been looking for a protocol to guide use of peripheral NA here in the UK.
        Would you mind sharing your protocol with me also? I think it’s a great idea.
        BW
        Pete

        • Hi Peter,
          You could really just do what the CENSER trial has done!
          4mg of noradrenaline in 250ml of 5% dextrose.
          Start at 0.05mcg/kg/min and then titrate up from that baseline.

          Big, fresh drip of long line above the ACF is required. The longer / more catheter in the vein the better.

          The protocol is pretty simple really and the new data from the CENSER trial makes me more confident that we should be doing this – especially in the smaller district hospitals where ICU is hours away and resources to place CVC are scarce.
          Safety is quite good – there are really very few extravasations and little charm documented in the literature

          We will be reviewing the trial in full in a few weeks.
          Casey

  4. David Berger says

    I would say over the last couple of years this has rapidly morphed into standard practice here in Western Australia, wouldn’t you say, Casey?

    I sent someone to Perth last week with spinal shock from Broome on a peripheral norad infusion, a six hour trip at best. We took the decision that this was far safer than placing a central line in the middle of the night in our tiny hospital with few resources and a tired operator. We now regularly receive inward flying doctors transfers on peripheral norad infusions, whereas a few years ago even wanting to start one in our hospital was a major cause of angst and stress for the nursing staff.

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