Initiation of Vasopressors via Peripheral Versus Central Venous Access in Septic Shock Patients within the Emergency Department: A Systematic Review of Safety and Mortality Outcomes

Abstract

Background: Septic shock is a life-threatening emergency characterized by vasodilatory circulatory failure requiring prompt vasopressor therapy. Traditionally, vasopressors have been administered exclusively through central venous catheters (CVCs) due to concerns about extravasation and tissue injury from peripheral administration. However, CVC insertion is time-consuming, technically demanding, and associated with serious complications, including central line-associated bloodstream infection and mechanical injury. Growing evidence suggests that initiation of vasopressors through peripheral intravenous catheters (PIVs) may be safe and may reduce critical delays in hemodynamic stabilization of emergency department (ED) patients with septic shock.

Objective: To systematically review published evidence on the safety, extravasation risk, mortality outcomes, and time-to-vasopressor initiation associated with peripheral versus central venous access for vasopressor administration in adult patients with septic shock presenting to the emergency department.

Methods: A systematic literature search of PubMed/MEDLINE, EMBASE, and the Cochrane Library was conducted for studies published from January 2000 through December 2023, following PRISMA 2020 guidelines. Eligible studies included randomized controlled trials, retrospective and prospective cohort studies, and systematic reviews reporting outcomes of peripheral versus central vasopressor administration in adult septic shock patients. Key outcomes included: extravasation and local tissue injury rates, mortality (28-day, in-hospital, 90-day), time to vasopressor initiation, and secondary outcomes (ICU length of stay, vasopressor duration, fluid administration).

Results: Ten studies meeting eligibility criteria were included, comprising one randomized controlled trial, five cohort studies, and four systematic reviews/meta-analyses, encompassing collectively over 4,000 patients. Extravasation rates with PIV administration in ED-specific studies ranged from 0% to 4.5%, with no severe tissue injury or limb ischemia documented in any ED cohort study. Twenty-eight-day mortality was comparable between PIV and CVC groups in all comparative studies, with no statistically significant difference identified. PIV administration was associated with significantly faster vasopressor initiation (79–126 minutes earlier), reduced total fluid administration in 24 hours (3,280 vs 4,050 mL), lower intubation rates in one large multicenter study (17.8% vs 40.5%), and avoidance of CVC placement in 33.8% of patients. The CENSER randomized trial demonstrated that early peripheral norepinephrine administration significantly improved shock control at 6 hours (76.1% vs 48.4%, p<0.001) and reduced 28-day mortality (15.5% vs 27.4%, p=0.040) compared with standard delayed resuscitation.

Conclusion: Peripheral vasopressor administration in ED septic shock patients is safe, with low extravasation rates and no documented severe tissue injury in ED-based studies. There is no mortality disadvantage compared with central venous administration, and PIV initiation is associated with faster hemodynamic stabilization and reduced procedural burden. These findings support the incorporation of PIV vasopressor protocols into ED septic shock management guidelines.