CONSIDER NOREPINEPHRINE ADMINISTRATION VIA A PERIPHERAL IV LINE INSTEAD OF A CENTRAL IV LINE

INTRODUCTION

In the human body, there is a hormone named Norepinephrine (H-NEP) that is produced by the Adrenal Glands. Norepinephrine is also known as noradrenaline and together with Epinephrine (H-EP), and Dopamine (H-DP), comprise what is called the catecholamine family. These hormones are directly responsible for acting on the brain's fight-or-flight response. The Nervous system has two parts: the Central Nervous System (CNS) composed of the Brain and Spinal Cord; and the Peripheral Nervous System (PNS) composed of the Nerves that branch off from the Spinal cord into the entire body. H-NEP is a neuromodulator of the PNS that is responsible for increasing the body's blood pressure (BP), heart rate (HR), respiratory rate (RR), etc.

On the other hand, there is also a drug called Norepinephrine (D-NEP) that was discovered in the USA during the 1950s. This drug acts identically to the naturally synthesized hormone norepinephrine (H-NEP), where it mimics its effects on directly affecting the sympathetic nervous system in increasing blood pressure and heart rate. Alpha-adrenergic receptors are found in the blood vessels of the brain and in the peripheries. These receptors are responsible for the modulation of the outflow from the sympathetic nervous system such as BP and HR. When given to the body, D-NEP can stimulate these alpha-adrenergic receptors and can temporarily reverse the onset of symptoms like hypotension due to shock.

The medical condition of shock in the human body is very serious, and most of the time is life-threatening. In this condition, the body's BP decreases dramatically and in turn, can affect the oxygen output to the different organs of the body. Vital organs such as the Brain, Heart, and Kidney are dependent on the oxygen output of the body through blood flow. But if blood flow is affected, these organs can be irreversibly damaged and can even cause death. The key to managing shock is to restore blood flow as quickly as possible to maintain oxygen supply to the vital organs. This is the reason why people who are experiencing symptoms of shock must be given immediate emergency attention. Every second counts in reversing the symptoms of a systemic shock as time is of the essence to save a life.

The standard practice of administering the drug norepinephrine (D-NEP) is via the intravenous (IV) route. The FDA has approved its use as a peripheral vasoconstrictor for BP control in patients who are experiencing hypotension due to shock. According to Smith, M., and Maani, C., (2019), D-NEP is the drug of choice as a first-line agent in many ICUs who oftentimes have to face sudden hypovolemic or septic shock with their patients especially if they do not respond to fluid resuscitation. The onset of activity on the administration of D-NEP is rapid (less than 30 seconds) according to Smith M., et al., (2019). The peak occurs within 5 to 10 minutes, and the duration lasts for less than 10 minutes after discontinuation of the infusion. The half-life and clearance of norepinephrine in adults are approximately 2 to 2.5 minutes and 24 to 40 mL/kg/minute, respectively. The short half-life of D-NEP is because the drug is rapidly inactivated by catechol-O-methyltransferase and monoamine oxidase in the liver and other tissues. While most of it is directly eliminated via the renal system.

Ideally, this is given through the Central Intravenous line (CIV) because D-NEP is known to cause tissue ischemia when it extravasates from the vein as a systematic review by Loubani and Green (2015) showed. But this paper aims to show that in the emergency room, the administration of D-NEP can be done via the peripheral intravenous line (PIV) without the risk of tissue ischemia.

SUPPORTING LITERATURE

Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated host response to the infection. There is an assessment tool for the body used in identifying any changes, like organ failure or dysfunctions due to infection. This tool is called the Sequential Organ Failure Assessment (SOFA). If the score of the patient's SOFA is 2 points or greater, then, the host has a life-threatening condition that is secondary to the infection cause (Singer M, et al., 2016). The resulting effect of organ failure would be a septic shock characterized by persistent hypotension that can only respond to vasopressors such as D-NEP. The early goal-directed therapy (EGDT) trial by Rivers et al., (2001), emphasizes on an early and aggressive fluid administration and resuscitation via an open intravenous line, usually with the use of a PIV. But oftentimes, during the shock phase, fluid volume resuscitation is not enough to increase the patient's blood pressure, that is why in an EGDT it is required that immediate vasopressors, such as D-NEP, must be administered and not delayed.

According to a review by Morgenstern, J., (2018), using the peripheral intravenous line (PIV) in administering the drug norepinephrine (D-NEP) and other vasopressor drugs is not allowed because of an old protocol based on a study in the 1950s that only focused on the adverse effects of administering D-NEP and other vasopressors via a PIV line. This protocol also considered a central intravenous (CIV) line is the only route of administration. Due to the lack of support, and overall impact on patient health, Morgenstern concluded that this protocol is just a myth as the data cannot be truly verified. Even more so today, that more and more reviews are scrutinizing this kind of protocol.

Other supporting literature shows that PIV administration of D-NEP is safe and effective for patients in the ER. Morgenstern, J., (2018), data analysis shows that there were 114 extravasation events from PIVs and that 75% did not result in any injury. Most incidents happened to patients who have PIVs places distal to the antecubital fossa, and that extravasation occurred at an average rate of 35 hours. Another study in support of using D-NEP via PIV was done by Cardenas-Garcia J., et al., (2015), where they performed a prospective observational study of adult patients receiving vasopressor medications through a PIV over a 20 month period at a single center ICU with strict protocols.

In a different viewpoint, a study conducted by Ricard JD., et al., (2013) randomized 263 patients from 3 different French ICUs. These patients were to be administered medications via a CIV or PIV. They found out that although there was a higher rate of complications to patients with PIV, it was also due to the fact that these complications came from difficulties in placing an IV and are not related to extravasation nor tissue ischemia. Tian, DH., et al., (2019), had a systematic review of 1500 patients who were given vasopressors, like D-NEP, had a 3.4% rate of complication that had no true adverse effects on patients. With the same intention as Tian, but in a different setting, Pancaro, C., et al., (2019), made a big retrospective study on 14,000 anesthesia patients and found out that the rate of extravasation is only 3 out of every 1000 cases. And even from this very small percentage, there were no adverse effects of tissue damage or life-threatening complications. Lastly, a study by Permpikul, C., et al., (2019), wherein they gave D-NEP and a placebo drug to two patient groups. The result was the presence of only one tissue ischemia in both groups. Thus concluding that PIV administration of D-NEP is not riskier than administering a placebo drug.

IMPLICATIONS TO CLINICAL PRACTICE

The implications of practicing the administration of the drug norepinephrine (D-NEP) via peripheral intravenous PIV line could be beneficial for the Nurse. Considering that this drug is mainly used in the Emergency Room (ER), where critical thinking and time management is of the utmost importance. Today, there are so many facilities around the world that lack adequate nurse resources. Understaffing plus the increasing age of the baby boomers are now affecting the healthcare landscape. This issue cannot be solved readily fast, that is why every innovative practice that saves time and resources must be given priority.

The nurse must consider the serious effects of sepsis on the cardiovascular system. The main reason is that the infection process could be faster and can trigger a chain reaction to all the other organs of the body. Disruption to the cardiovascular system is due to a loss of tone and integrity of the body's blood vessels because of the increasing presence of inflammatory cytokines. Peripheral arterial dilation, diffuse capillary leak, decreased contractility, and reflex tachycardia are some of the serious complications that could occur. The nurse should be aware that patients with sepsis may at some point exhibit diastolic hypotension including decreased arterial pressure. This in turn directly affects the nervous system wherein the patient may show signs of delirium, this can eventually complicate the condition and impact prognosis. According to Scalfani MT, and Diringer MN. (2011), as many as 70% of patients with severe sepsis develop encephalopathy, which is associated with worsened outcomes. This is caused by several factors and this includes the vasoactive response of the blood vessels resulting in an increased production of nitric oxide that can disrupt the blood-brain barrier (BBB) and cause severe inflammation of the central nervous system. Increased vasoactivity of blood vessels can cause more leukocyte recruitment to cross over the BBB in which an autoimmune response happens. Not to mention the decreased perfusion of oxygen toward the brain.

In the ER, patients who are admitted, are immediately started with a PIV to ensure there is an open-access for administering medications immediately. If a sudden onset of hypotension due to shock manifests in a patient, then D-NEP administration must be done immediately. But since the protocol of D-NEP administration is only allowed via a CIV, then the nurse must practice critical thinking. The nurse should have a thorough knowledge of how D-NEP affects the Alpha-adrenergic receptors located in the arteries so as to discuss with the physician the best and quickest way to manage the emergency. Ultimately, CIV insertion is time-consuming compared to PIV insertion. So as not to waste precious time, the nurse can help suggest to the physician to start a D-NEP infusion via a PIV for the purpose of immediate reversal of hypotension.

A study was done by Jones L., et al., (2018) on the effect of PIV administration of D-NEP on the patient's overall health, and concluded that unnecessary CIV insertions can be prevented through timely D-NEP administration via PIV. It was also concluded that patients without unnecessary CIVs, have better prognoses and survival rates. Also, administering high doses of D-NEP via PIV infusion is still safe and even conducive to reversing symptoms of emergency hypotension due to shock according to Lampin, ME., et al., (2012).

CONCLUSION

There are always risks to consider in administering IV medications. This is more true in the case of norepinephrine administration due to past studies of tissue ischemia. But the literature in this paper supports the idea that it is safer and more conducive to the patient's overall health if unnecessary cardiac intravenous (CIV) insertions can be prevented. Especially when peripheral intravenous (PIV) administration of D-NEP is timely. The data showed that tissue ischemia due to PIV administration of D-NEP is a rare occurrence. Therefore the practice must be considered with more support.

This is even more important in the field of nursing wherein patient safety is the priority. It is, therefore, the responsibility of the nurse to make sure the patient's IV line is of the highest quality. The nurse is to make sure there are no signs of infiltration, extravasation, inflammation, or other IV complications. Patient education about IV site care must be reinforced by the nurse so as to prevent unwanted contraindications, such as taking Blood Pressure (BP) on the arm with an IV line. Cutting off the vasopressor infusion through intermittent BP monitoring on the IV arm could lead to serious complications not only to the site itself but more so to the overall prognosis of the patient. It is also worth considering that CIV comes with its own risks such as arterial punctures, pneumothoraces, infections, and deep vein thrombosis (DVT) which could be more fatal and disruptive to the patient. Therefore establishing the nurse's role in rendering the best possible care must be reinforced.

Lastly, the nurse must remember in an emergency situation, early goal-directed therapy (EGDT) must focus more on the patient's overall health and response to therapy rather than protocols that may compromise the life of the patient.

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