Incidence of Adverse Events in Peripheral Intravenous Vasopressor Use: A Systematic Review and Meta-Analysis.

Abstract

Peripheral intravenous (PIV) vasopressors are increasingly used but remain associated with adverse events (AEs). Quantifying the incidence of these AEs is essential to guide clinical decision-making regarding PIV vasopressor use. To assess the incidence of AEs and avoidance of central venous catheter (CVC) placement after PIV vasopressor administration in adults with hypotension, shock, or critical illness. PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to December 13, 2025, using medical subject headings and keywords related to peripheral vasopressors. Eligible studies included critically ill adults receiving vasopressors via PIV catheters and reported AEs and/or CVC avoidance. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 2 investigators independently extracted data and assessed risk of bias. A random-effects model was used, and proportions were pooled using a generalized linear mixed model. The primary end point was the pooled incidence of AEs as the proportion among total catheters, and the secondary end point was the pooled proportion of CVC avoidance. Forty-nine studies including 33 060 catheters were analyzed. The pooled minor AE incidence was 2.6% (95% CI, 1.4%-4.7%) for norepinephrine, 0.0% (95% CI, 0.0%-24.6%) for epinephrine, 2.9% (95% CI, 1.8%-4.8%) for phenylephrine, 1.4% (95% CI, 0.3%-5.9%) for dopamine, 0.5% (95% CI, 0.1%-1.8%) for vasopressin, and 0.9% (95% CI, 0.1%-11.5%) for metaraminol. When considering all vasopressors collectively, the pooled minor AE incidence was 2.3% (95% CI, 1.5%-3.7%). Regarding major AEs, 30 venous thromboembolism events occurred, all in the 4 studies (8.1%) using midline catheters (1126 total catheters), with a pooled incidence of 1.4% (95% CI, 0.4%-5.4%). In contrast, only 1 major AE (a tissue necrosis event) was reported in 43 studies (87.8%) using short PIV catheters (29 596 total catheters), with a pooled incidence of 0.0% (95% CI, 0.0%-0.0%). CVC avoidance ranged from 0% to 100%, with a pooled proportion of 59.7% (95% CI, 46.4%-71.7%) in 38 studies (77.6%) including 15 371 catheters. In this systematic review and meta-analysis of adult patients, AE incidence was low after short-term vasopressor administration through PIV catheters, particularly short catheters. These findings suggest that PIV administration might reduce the need for CVC placement with appropriate monitoring.