Do ICUs adhere to new peripheral vasopressors guidelines?

Background

In response to Intensive Care Society (ICS) recommendations in 2020, an NHS Trust amended their peripheral vasopressors within critical care guidelines to use noradrenaline as first-line, preferentially to metaraminol. To assess the impact of the new guideline, an audit was conducted across two intensive care units (ICUs) to quantify guideline adherence, assess deviations, and evaluate associated extravasation incidence.

Objectives

• The objective was to evaluate peripheral vasopressor choice in adult critical care patients and quantify extravasation rates.
• Standard: 100% noradrenaline prescribed as peripheral vasopressor in critical care patients between August and December 2023.

Method

A retrospective audit was conducted with 70 patients admitted across two ICUs between 1 August and 31 December 2023. Data was collected from electronic prescribing and medical records. Inclusion criteria encompassed patients aged 18 years or older and treated with noradrenaline or metaraminol as peripheral vasopressors during their ICU admission. This audit did not require ethics approval but was approved by the Trust clinical effectiveness department. 

Results

Metaraminol was the most frequently used peripheral vasopressor (63%), followed by noradrenaline (37%), therefore the audit standard was not met. Wider data was generated which revealed that the mean duration of metaraminol (55hrs) was shorter than noradrenaline (59hrs) with more escalation to a central vasopressor within the metaraminol group (48% compared to 42% for peripheral noradrenaline).

Significant variation across sites was noted. Extravasation occurred in 13% of patients that received peripheral vasopressors. Direct comparison of the two agents under evaluation revealed a higher extravasation rate with metaraminol (16%) compared to noradrenaline (8%), contrary to previously reported peripheral noradrenaline extravasation rates, challenging current published literature.

Conclusions

This audit helped to determine peripheral vasopressor usage patterns within the ICU. A key finding was that despite ICS and local guidelines, metaraminol continued to emerge as the favoured first-line peripheral vasopressor at this Trust with differences seen across the two sites. Proposed reasons for non-compliance may lie in prescriber misconceptions, preference or initiation outside of ICU.

Increased rates of extravasation have been previously reported. Subsequent investigations are required to explore a wider patient population and further understand the risks of extravasation between both agents respectively. Furthermore, local education to raise awareness of noradrenaline as first-line peripheral vasopressor is required. Re-audit will be required to assess uptake, future adherence and extravasation rates to help close the gap between evidence-based recommendations and clinical practice.

Additional authors: Joy Simiyu, Emma Smith, Emma Graham-Clarke

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.