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Use of peripheral vasoactive drug infusions during the critical care transport of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 infection
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  1. Mithila D'Souza,
  2. Susannah Pye,
  3. Elise Randle,
  4. Padmanabhan Ramnarayan,
  5. Andrew J Jones
  1. Children's Acute Transport Service, Great Ormond Street Hospital for Children, London, UK
  1. Correspondence to Dr Mithila D'Souza; mithila.d'souza{at}gosh.nhs.uk

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Paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS)—also known as multisystem inflammatory syndrome in children (MIS-C)—frequently presents with signs of shock and is treated with vasoactive drugs.1 Infusing vasoactive drugs via a peripheral venous line (PVL) has utility in the acute setting but carries the risk of extravasation.2

We report on a cohort of children with PIMS-TS/MIS-C who received epinephrine and/or norepinephrine infusions via a PVL during transport to a paediatric intensive care unit (PICU) between 1 August 2020 and 28 February 2021. The diagnosis of PIMS-TS/MIS-C was made by a multidisciplinary team. The initial choice of vasoactive drug(s) and route of administration was decided by the transport consultant and the referring team, with reference to service guidelines.3 During the study period epinephrine and norepinephrine for peripheral administration were made as 0.3 mg/kg in 50 mL diluent for children up to and including 13 kg, and 4 mg in 50 mL for children over 13 kg. Service guidance mandates that the vasoactive drug infusion site is checked at least every hour.

Discrepancy between cuff and invasive blood pressure (BP) measurement in children has been described4; therefore, data were also gathered on vasoactive drug dosing in children with and without arterial lines.

Forty-five children with PIMS-TS/MIS-C received vasoactive drugs via a PVL during transport, of whom 18 received epinephrine only, 23 norepinephrine only, and 4 both epinephrine and norepinephrine. Only one child in this group was invasively ventilated. In the same period, five children with PIMS-TS/MIS-C received vasoactive drugs via a central venous line (CVL) and one child via an intraosseous line, of whom three were invasively ventilated. The PVL and CVL (including intraosseous) groups are compared in table 1.

Table 1

Characteristics of children receiving vasoactive drugs by PVL or CVL

There was one extravasation injury. This occurred after transport had been completed in a 72 kg adolescent at hour 21 of a norepinephrine infusion via a hand PVL (maximum dose 0.2 μg/kg/min). There was minimal swelling and no sign of tissue ischaemia. The site was washed out with 0.9% saline and healed completely.

Twenty-eight of 45 children (62%) transported on PVL vasoactive drugs did not require CVL insertion within the first 24 hours of their PICU admission; and 17 of 28 (61%) children transported on PVL vasoactive drugs had the infusion(s) discontinued within 6 hours of PICU admission. All children survived to discharge.

Statistical analysis of the doses of epinephrine and norepinephrine used on transport in those with and without an arterial line is limited by small numbers (table 2), but application of the Mann-Whitney U test did not suggest a difference between the two groups. Thirty-four of 40 children transported without an arterial line went on to have one inserted on PICU within 24 hours.

Table 2

Comparison of the doses of epinephrine and norepinephrine used for children receiving vasoactive drugs with and without an arterial line on transport

Our experience suggests that the use of vasoactive drugs via a PVL is safe during transport of children with PIMS-TS/MIS-C. To further mitigate risk, as of March 2021 our service has been using a more dilute concentration of norepinephrine for peripheral administration (0.8 mg in 50 mL for all ages). The data signal that an absence of invasive BP monitoring does not lead to higher doses of vasoactive drugs. Peripheral administration of vasoactive drugs may have benefits in terms of reducing CVL morbidity, PICU length of stay and costs. At 24 hours, 5 of the 28 children who had not required a CVL had also not required an arterial line, suggesting that some cases of PIMS-TS/MIS-C with shock can be safely managed without recourse to invasive procedures.

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Footnotes

  • Contributors AJ and MD'S designed the study, collected and analysed the data, drafted and revised the manuscript, and approved the version to be published. SP and ER identified the patients, performed data collection, reviewed the manuscript and approved the version to be published. PR assisted with data analysis and interpretation, reviewed the manuscript, and approved and revised the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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