Navigating the veins: A comprehensive review of vasoactive agent infusion via peripheral routes

Table 1 Summary of recent trials evaluating the complications associated with transfusion of vasoactive agents through peripheral intravenous catheters, median (25^th-75^th percentiles)

Ref.	Year of publication	Country of origin	Type of study	Patient population	Sample size	Extravasation	Thrombosis	Infection	Vasopressor	Duration of vasopressor
Ramanan et al[13]	2025	Australia	Prospective single center RCT	ER/ICU	40	2/40	NA	1/40	Noradrenaline	11.5 (6.5-23.5) hours
Petros et al[14]	2025	Ethopia	Multicenter prospective cohort	ER/ICU	250	3/250	NA	NA	Noradrenaline, adrenaline, dopamine	NA
Christensen et al[15]	2024	Sweden	Multicenter prospective observational study	Perioperative	1004	23/1004	NA	NA	Noradrenaline	175.5 (105-276) minutes
Han et al[16]	2024	China	Retrospective, single center cohort study	Neurology ICU	273	1/273	NA	NA	Metaraminol	88.4 (54.5-131.6) hours
Asher et al[17]	2023	Israel	Prospective single center study	Cardiology ICU	108	1/108	NA	1/108	Noradrenaline, adrenaline, dopamine	NA
Powell et al[18]	2023	United States	Retrospective, single center cohort study	NA	36	0	0	0	Noradrenaline	6 (3.3-11.3) hours
Marques et al[19]	2022	Rwanda	Prospective single center study	ER/ICU	64	2/64	NA	NA	Noradrenaline, adrenaline	19 (8.5-37) hours
Groetzinger et al[20]	2022	United States	Retrospective, single center study	Medical ICU	87	1/87	NA	NA	Noradrenaline	1-68 (range)
Nguyen et al[21]	2021	United States	Retrospective, single center study	ER	177	4.5%	NA	NA	Noradrenaline	62 (32-142) minutes
Ballieu et al[22]	2021	United States	Retrospective, single center cohort study	Neurology ICU	125	2/125	1/125	NA	Phenylephrine	NA
Delaney et al[5]	2020	Australia	Post-hoc analysis of the ARISE trial	ER/ICU	548	3/548	1/548	1/548	Noradrenaline, adrenaline, dopamine	4.9 (3.5-6.6) hours
Padmanaban et al[23]	2020	India	Single center, observational study	ICU	122	1/122	NA	NA	Norepinephrine, vasopressin, adrenaline, dopamine	Noradrenaline 9 (6-14), vasopressin: 4 (2.7-9), adrenaline: 6 (4-10), dopamine: 7.5
Lewis et al[10]	2019	United States	Retrospective, single center cohort study	ICU	202	8/202	NA	NA	Norepinephrine, epinephrine, vasopressin, dopamine	11.5 hours (median)
Medlej et al[24]	2018	Lebanon	Single center, observational study	ER	55	2/55	1/55	0/55	Norepinephrine, dopamine	Norepinephrine: 13 (6.5-31.5); dopamine: 53 (15.5-113) hours
Datar et al[8]	2018	United States	Retrospective, single center study	Neurology ICU	277	9/277	NA	NA	Phenylephrine	19 ± 18 hours
Delgado et al[25]	2016	United States	Single center observational study	Neurology ICU	20	1/20	0	0	Phenylephrine	14.29 (1-54.3) ours
Cardenas-Garcia et al[9]	2015	United States	Single center observational study	MICU	734	19/734	NA	NA	Norepinephrine, dopamine, and phenylephrine	49 ± 22 hours

RCT: Randomized controlled trial; IQR: Interquartile range; ER: Emergency room; ICU: Intensive care unit; MICU: Medical intensive care unit; NA: Not available.

Table 2 Practical considerations for peripheral intravenous catheter placement

Sites to avoid	Reason/comment
Dominant upper extremity	Movement may lead to patient discomfort and increase risk of dislodgement
Sites over joints	Increased risk of catheter kinking or dislodgement
Lower extremities	Increased risk of thrombophlebitis and deep venous thrombosis due to static blood flow
Extremities with arteriovenous fistula	Inserting a catheter may disturb the venous blood flow or damage the fistula
Burns or infected tissue	Increased risk of systemic infection
Evidence of sclerosis or phlebitis	This may be indicative of disrupted venous integrity and a higher risk of extravasation
Sites where catheter was recently placed or attempted (especially in the presence of hematoma)	This may be indicative of disrupted venous integrity and a higher risk of extravasation

Table 3 Studies reporting maximum dosage and duration for different vasopressors, mean ± SD

Ref.	Year of publication	Studied vasopressor	Study type	Number of patients	Maximum dose studies	Maximum duration (hours)	Complications reported	Rate of complications
Cardenas-Garcia et al[9]	2015	Noradrenaline	Prospective	506	0.7 ± 0.23 mcg/kg/minute	49 ± 22	Extravasation	16/506
Putland et al[45]	2006	Adrenaline	Retrospective	220	1.5 mcg/minute	19.5 (median)	Extravasation	11/220
Cardenas-Garcia et al[9]	2015	Dopamine	Prospective	101	12.7 mcg/kg/minute	49 ± 22	Extravasation	3/101
Cardenas-Garcia et al[9]	2015	Phenylephrine	Prospective	176	3.25 mcg/kg/minute	49 ± 22	Extravasation	0
Lewis et al[10]	2017	Vasopressin	Prospective	4	0.04 units/minute	12.5	Extravasation	0

Table 4 Measures to ensure safe use of peripheral venous lines

Avoidance of high-risk sites	Upper extremity only (avoiding joints)
Large size vein	Choosing vein with diameter more than 4 mm (to be measured using ultrasound)
High bore cannula	Intravenous line size 20 gauge or 18 gauge
Confirmation of cannula position	Using ultrasonography, position of cannula should be ascertained before initiating vasopressors
Check backflow	Blood return should be checked before initiation of vasopressors
Evaluation of PVC function	PVC function should be assessed regularly (every 1-2 hours)
Staff education and training	Close monitoring of PVC site for any signs/symptoms suggestive of complications
Managing complications	Standardized protocol for managing extravasation
Short duration of therapy	PVC use should be limited to a maximum of 72 hours

PVC: Peripheral venous catheters.

Table 5 Different treatment options for management of extravasation of various vasoactive agents

Vasoactive agent	Suggested antidotes
Noradrenaline	Subcutaneous phentolamine. 2% topical nitroglycerin ointment Subcutaneous terbutaline
Adrenaline	Subcutaneous phentolamine
Dopamine	Subcutaneous phentolamine. Topical nitroglycerine. Topical nitroprusside. Subcutaneous terbutaline
Dobutamine	Subcutaneous terbutaline. Subcutaneous phentolamine. Topical nitroglycerine
Phenylephrine	Subcutaneous terbutaline
Vasopressin	Subcutaneous phentolamine. Topical nitroglycerine