SAQ 325 – Resuscitation – peripheral noradrenaline in septic shock
Model Answer
Resuscitation – peripheral noradrenaline in septic shock.
a. Peripheral vasopressor use
- Advantage: vasopressor therapy can start immediately without waiting for central venous access, reducing ongoing organ hypoperfusion.
- Safety: extravasation is uncommon, with reported rates under 2%, and ischaemic complications are very rare when the cannula is monitored.
b. Risk reduction
- Use a well-sited peripheral IV cannula; if ultrasound guided, confirm more than 10 mm of catheter lies within the vein.
- Perform regular checks of the cannula site for pain, swelling, blanching, or leakage.
c. Extravasation management
- Stop the infusion immediately.
- Establish alternative IV access.
- Aspirate through the affected cannula if possible.
- Administer a vasodilator, such as subcutaneous phentolamine 0.5 mg/mL using a 25-gauge needle; it may also be given through the cannula before removal.
- Observe the limb closely after treatment.
d. Confirming venous CVC placement
| Method | Expected finding |
|---|---|
| Chest X-ray | Tip projects in the SVC, above the right atrium. |
| Point-of-care ultrasound saline flush or wire check | Flush is seen in the right atrium or the wire moves freely within the internal jugular vein. |
| Blood gas from the line | Venous gas pattern with low pO2 and oxygen saturation compared with arterial blood. |
e. Second-line agent
| Echo finding | Second-line agent |
|---|---|
| Poor LV systolic function | Adrenaline or milrinone. |
| Hyperdynamic LV function | Vasopressin. |
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