A patient with a diagnosis of urosepsis has been admitted to the ward. You have been asked to start noradrenaline for hypotension. What is the normal route of administration?

1. A

   Wide bore cannula in the posterior tibial vein

2. B

   Peripheral cannula

3. C

   Wide bore cannula placed in the brachial vein

4. D

   Central venous line in the subclavian vein

Appeared in: AIIMS Rishikesh & Jodhpur NO - 2017

Explanation

• Noradrenaline is a potent vasoconstrictor and a vesicant, meaning it can cause severe tissue damage if it leaks out of the vein (extravasation).
• To prevent extravasation and ensure rapid dilution, it must be administered into a large, central vein with high blood flow.
• A central venous line placed in the subclavian, internal jugular, or femoral vein provides this necessary safe access.
• The tip of the central line catheter is positioned in a large vessel like the superior vena cava, allowing the potent drug to be diluted quickly and safely distributed throughout the body.

Why Other Options Were Wrong

• Option A: The posterior tibial vein is a peripheral vein in the lower leg. Administering noradrenaline here carries a very high risk of extravasation and severe tissue necrosis, similar to any other peripheral site.
• Option B: A standard peripheral cannula, regardless of location (e.g., hand or forearm), is not suitable for noradrenaline infusion due to the high risk of extravasation and subsequent tissue death.
• Option C: The brachial vein is a large peripheral vein in the arm, but it is still not a central vein. The risk of extravasation and severe tissue damage remains unacceptably high for a noradrenaline infusion.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Route of Administration for Vasopressors to guide bedside assessment, documentation, and the next nursing action.
• A nurse's primary responsibility when administering vasopressors is to ensure the line is patent and correctly placed. Always confirm central line placement (e.g., via X-ray) before starting the infusion.
• Frequent monitoring of the insertion site for signs of infiltration (swelling, pain, coolness, blanching) is critical, even with a central line.
• Patient Safety: Never administer vasopressors like noradrenaline through a peripheral line unless it is a dire emergency and for the shortest possible time while actively securing central access.

How to Approach the Question

• First, identify the drug in question: Noradrenaline.
• Recall or look up the properties of this drug. Noradrenaline is a potent vasopressor and a known vesicant (can cause tissue damage).
• Consider the primary risk associated with administering a vesicant drug: extravasation and tissue necrosis.
• Evaluate the options based on which route minimizes this risk. Peripheral routes (in the arm, leg, or foot) have a high risk of extravasation.
• A central venous line delivers the drug into a large vein with high blood flow, allowing for rapid dilution and minimizing the risk of tissue damage. This is the safest method.
• Select the option that describes central venous access.

Concept Tested & Keywords

• Concept Tested: Route of Administration for Vasopressors
• Stem keywords: urosepsis, noradrenaline, hypotension, route of administration
• Lead-in keywords: What is the normal route
• Clinical cues: The patient has urosepsis and hypotension, indicating septic shock which often requires vasopressor support.

Question ID

Q1k5acW6nNHlIQlgGxjCFZ

Copy ID

Reference Book

E6 Medicine Davidson Principles Practice 24e p. 226-228

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 777-779

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 615-617