Mount Sinai Med-Lit Review
Clinical question: Can vasopressors be safely administered through a peripheral line?
Background: Traditionally, clinicians have administered vasopressors through central venous catheters (CVCs) due to case reports in the 1950s and 1960s of catastrophic tissue injury from extravasation. Recent evidence suggests that initiating vasopressors through peripheral intravenous catheters (PIVs) is low risk, though multicenter data on the safety of peripheral vasopressor use remain limited.
Study design: Prospective, nonrandomized, cohort study conducted as a secondary analysis of the CLOVERS trial
Setting: Multiple U.S. centers
Synopsis: The study included 582 patients from 60 U.S. hospitals between March 2018 and February 2022 who received vasopressors for sepsis-induced hypotension within 24 hours of enrollment and did not have central access at the time of enrollment.
Most patients received vasopressors via a peripheral catheter (84.2%). Peripheral vasopressors continued past six hours in 68.0%, with rare, minor complications (0.6%), and no tissue injury. CVC placement led to complications in 3.7% of patients.
There was no significant difference in 90-day mortality between peripheral (26.1%) and central (37.0%) vasopressor initiation (adjusted odds ratio [OR], 0.67; 95% confidence interval [CI], 0.39 to 1.16).
Peripheral initiation was associated with a shorter time to vasopressor start (adjusted difference, -2.3 hours) and lower 24-hour fluid volumes (adjusted difference, -686 mL).
Limitations include that midlines and PIVs were all classified as peripheral, which limits generalizing safety to peripheral IVs (perhaps midlines are safer?) Additionally, as in any nonrandomized cohort study, confounding is always a risk.
Bottom line: Starting peripheral vasopressors for early sepsis in an appropriately monitored setting carries low risk for the traditionally feared catastrophic outcomes. Peripheral administration also avoids treatment delays, avoids the risks associated with CVC placement, and reduces the 24-hour fluid volume.
Citation: Munroe ES, et al. Peripheral vasopressor use in early sepsis-induced hypotension. JAMA Netw Open. 2025;8(8):e2529148. doi: 10.1001/jamanetworkopen.2025.29148.
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Dr. Mergl
Dr. Mergl is a hospitalist at the Mount Sinai Medical Center and an assistant professor at the Icahn School of Medicine at Mount Sinai, both in New York.