The way the question was sort of, you built up to it, it's kind of like, well, what would you do once you've already had a complication of peripheral vasoconstrictor administration? Kind of a little bit of a separate issue. And I'm just kind of thinking, you know, if this patient went somewhere and you say they were rushed to the operating room, it kind of would be inconceivable to me that they wouldn't come out of the operating room with the central line, you know, while people were administering papaverine locally to reverse the effects of the prior peripheral administration. So I don't want to make too much work, but if you simply said there was an RRT called on a patient, you know, very short, and they're currently significantly hypotensive, could you make the question, the appropriate administration of norepinephrine would be via, number one, the existing peripheral line, number two, not to be started until central venous catheter, you know, et cetera, interosseous, and then midline catheter. Then you could say everything you said, and you know, where guidelines have come down on it, that the time and problems of getting any of those other accesses doesn't warrant it. Nonetheless, there can be problems, and indeed this patient, they show that nice photograph, but the patient was rescued, you know, even though the recommended intravenous route was used, and then that feeds into your discussion about even when you do get a complication with a peripheral line, early recognition of it and proper steps can ameliorate the effects. Is that? Okay, yeah, I built this question because I wanted to include that photo as I started collecting photos. Yeah, no, this is actually a case that played out exactly like this. The patient did not have a central line from the OR a couple of days ago, but I can certainly... No, I meant when they went in to get their papaverine treatment. I bet they'd come out, I mean, well, at least my folks would sort of make sure that, okay, you know, once bitten, twice shy. Sure. Yes, so you just maybe structure it, and don't get into the, you know, just say you're at RRT, here you are at the bedside, you want to hang norepinephrine, which is fully appropriate, and what do I do next? Do I delay, because three things are essentially delaying three routes, or, you know, establishing new access, or use the access I got, and that's good, and then you can say, and studies and guidelines have supported that, but no route is perfect. You know, each of the routes come with complications, and indeed, in this patient, there was a problem, and it had to be addressed, but when you use a peripheral line, you look exactly for these kinds of difficulties, and if you identify them early, it's still okay. Is that a way to piece it together? I think 100%. So, just to summarize, make sure I understood correctly, sort of similar stem, much shorter, stop at the point of now the patient's hypotensive and needs pressors, and sort of ask the question of what is the best route for pressors in this situation. Central line, this is three things, so I would do maybe central lines, midlines, what would my three choices be? Well, you could say immediate administration of norepinephrine through the existing peripheral venous access, or norepinephrine after central venous access is achieved, norepinephrine after interosseous access is achieved, and just say that, because that's, B is a complicated choice, because then it presumes that you did try A, but somehow you couldn't get it, you know, there's nothing about the patient yet that we've learned that means you couldn't get central venous access, you know, so, or establish a, and basically, you don't, any of those things are going to take time, and time's not on your side when you're treating shock, and, you know, interosseous placement's going to hurt like bejesus. Yeah, got it, and then keep the bulk of the commentary with the same content, but make the point of you want to correct the hypotension at the point about different, the pros and cons, and the guidelines, and then no route is perfect. Right, no line is perfect, and they each have their things to watch for, and in this case, watching carefully showed that you had to stop that peripheral administration, because there was some extravasation with local effect, but you have a treatment for that if you find it early and act definitively. That sounds good for me, sorry. I think it would be an opportunity, I know it's not the focus of your question, but just have a sentence or two about the treatment of this complication in your commentary. You mentioned it's a complication, but I don't think it says how you would go about treating it. Now, the question itself describes the treatment, so it is there, but you know, perhaps having a sentence in the commentary would be helpful. I agree, and in the new version, the question won't describe the treatment, because it's just adjusting, so I'll include it in the, remove the catheter, you know, all these other things. How was the, no, but it just says injection of papaverine, was this through what route? I think into the vessel is what I think they do. Arterial or into the venous system? I want to say, sorry, Jessica. Yeah, I think it would be arterial injection. Because otherwise I was going to ask, would you have normally sent this person for an angiogram? Like, was it more for therapy or diagnosis? It seemed, if you just started infusing above this area, that that would probably be your first, most likely cause of the presentation you're describing. I think, and I wasn't the one taking care of him at the time, but I think they moved quickly because of the concern that there was clot. Now, reading the whole thing and knowing that pressers were going in and it's radial and ulnar, like, why should there be clot all of a sudden? That clinically doesn't seem to be what happened. It seems obviously more like vasospasm, but that, I believe in that quick flush of things, let's just go to the OR and see what's going on. Certainly not questioning the management, you do things in management. I think that's how, I mean, just you say what you, you can say what parts of it you want in the question, just, but, you know, I'm not questioning that it was managed properly. No, no, no, no, no. I think that that, as I was writing this stem, that was really what was in my mind, but rewriting it the way Jesse suggested, it'll stop before that part. And then in the commentary, I can just put a little bit about, yes, this complication can happen. How should it be managed? And that will touch upon all the different things we're talking about. Does that sound? Sounds good. Sounds good to me. Usually when you get extravasation, there's always the potential for a combination of vasoconstriction and clot. I mean, flow gets so low that clotting becomes a risk. Now this patient may have still had effects of anticoagulation, et cetera, but clots always a potential. So I think vascular surgeons ideally would like to see what they have, you know, in some cases they might end up actually removing clot. In some cases, they might simply reverse vasospasm and some cases they might do both. And it sounds like in this case, they were able to, and not futz around, you know, some recommendations are for local injections of vasodilators or administration of topical vasodilators on the extremity. I don't think they do much of anything. So I think if it's early and it's profound and you're at risk for, you know, losing a hand, you're with no pulses at all, you're going to go full tilt to define what the anatomy is. And if you can reverse just vasospasm, you're done. And if there's still clot, you've, you remove it. Yeah, that's fine. That's would be standard. If somebody who's in shock and you're stopping pressors and you have a potentially easy solution of infusing some paverine, I wondered if that might just be tried first and then a failed, you go for the angiogram, but either way, it's not. Yeah. I think for extubation and no other vascular compromise, certainly putting half the dose of the vasodilator through the existing IV and the other half around is at least what the guidelines in our hospital. But what I will do is I will look up sort of what's the evidence base for each of these, and then put in a short paragraph about management of this complication. And this comment's even less valuable. So I apologize, but was it a bleed that led to the shock? What did lead to the shock? Only asking because the heart rate was pretty low for someone in shock. And I wasn't, you know, I was thinking in my head, why could that be? The heart rate was 70, I think. If I recall correctly, and I think this, I don't know if he was on any AV nodal blocker. He's a history of AFib, so maybe not a rate controlling agent. I think that the retroperitoneal bleed is something he did not end up having. I don't recall if it shook out to be sepsis or something else. Do you want to make it a little bit more a septic story? Because another argument somebody might make or concern a person might have would be that, look, if it's hypoblemic shock from a retroperitoneal bleed, you ought to just get on volume resuscitation and you won't be on norepinephrine at all. So that can be fast. So make it a little bit more. I'll push it in the sepsis direction. Yeah. My thoughts are pretty much echoed by the group. I think a lot of us, when we write questions and do it based on a patient that we took care of, love putting in the full history because it's so vivid in our minds and we like to present the story. But I think in addition to stopping where Jesse suggested, you may just kind of trim some of the history, whether he got his transplant is probably irrelevant and some other pieces, just to make that a little shorter. The papaverine, I agree. I wanted to know more about that. I haven't been in this situation. So in a way, I wanted to be educated. When do I give this papaverine? What is it? It's an antispasmodic and how it's delivered, those comments were made. The pic is another great picture. You guys have totally set the bar way high here. I guess my question is, it's great where it stands, but would it be better to put it in the commentary and just sort of describe something here? Yeah, that's like, well, based on the changes we discussed, even the description and the picture will both be in the commentary, right? Okay, perfect. So we won't get to this complication in the question stem. And my last comment, and again, I need the experts of the group to comment, but is there any relationship between the dose of norepinephrine and the incidence of these complications? There is, I don't know what the data is, but certainly there are limits, I think, in pretty much every hospital and basically in the guidelines to what rate and what concentration you can put through a peripheral IV, because the more ways of spasm you're going to get. But those upper limits, I think, vary by hospital, but are generally lower than what you can give through a central line. And that is in the guidelines and it is in the commentary. But if you want me to add more detail, I can look for it. I guess the question is based on, like, if you were to give someone five mics of Levimifed, would you expect to see this? Is it dose dependent or is it? I don't think it's very dose dependent. It's infiltration dependent. And usually hospitals have one or two concentrations of norepinephrine in the bag and then it's infused at different rates to achieve the administration difference in the amount of drug given per unit time. But what gives you the mess when you have an infiltrative IV is how much of either concentration A or 2XA you get locally. And that's probably dictated by how bad the leak is of the peripheral site and how much the tissues can accept before the system starts beeping. So I don't think I'd even go there. I think you can see this at low infusions rates with low concentrations of norepinephrine because the local concentration of norepinephrine is through the roof in the arm. Yeah, I don't think there's a threshold effect for sure. But if you are going to lose some, you'd rather lose less than more. I think that's basically what I mean. Yeah, I wouldn't go there. I mean, anything you're infusing at any low, medium or high dose relatively diluted, relatively concentrated, I think you have a potential for problem because of how much is present locally. Yeah. And I think maybe most places that will allow peripheral pressors, which I think is pretty much every place now, you'll see something like this or a complication of even an IO after an arrest. But peripheral IVs are being used so much now for pressors that I figured between the photo and including that topic was tempting. But I, okay, so to summarize the changes I have to make, overall, shorten the question, including trim out the history. I will push the question stem in the direction of suggestive of sepsis. I will stop the question before this complication happens and simply at the point where pressors are needed. And then the question will be the appropriate next step for administration of pressors is use the existing peripheral IV, central venous IO, midline, then go into the answer and explanation, expand on the bit about complications can occur. This in fact happened to this patient and how to recognize and manage it. And I will cut down the number of references. Yeah. I think that really will be a very informative question. We'll work on it.

medical case

peripheral vasoconstrictor

pressor administration

extravasation

vasospasm