Daria Renata Borakowska, Rafał Podgórski, Edyta Łuszczki

Aspects of safety pharmacotherapy in cardiogenic shock

 

2025-10-31

Subject of Study. Cardiogenic shock is a life-threatening condition resulting from primary cardiac failure leading to a critical reduction in cardiac output, despite typically elevated systemic vascular resistance. The most common etiology is acute myocardial infarction, although cardiogenic shock may also arise as a consequence of severe arrhythmias, valvular dysfunction, or cardiomyopathy. Pharmacological management of cardiogenic shock is tailored to the clinical presentation and may include catecholamines (dopamine, dobutamine, norepinephrine) for impaired myocardial contractility, epinephrine and atropine for bradycardia, nitroglycerin and furosemide for pulmonary congestion, and amiodarone for arrhythmias. The solutions of these drugs, with the exception of furosemide, are acidic (pH < 5), whereas furosemide is alkaline. Administration through a central venous catheter is preferred to reduce the risk of severe soft-tissue injury due to their non-physiological pH. In patients without central venous access, vasoactive agents are administered via peripheral cannulas, which raises concerns regarding safety.

Objective. To evaluate materials of infusion sets and clinical practices that mitigate the risk of complications during administration of drugs most commonly used in cardiogenic shock (catecholamines, nitroglycerin, amiodarone, furosemide, atropine) in patients without central venous access.

Methods. A narrative review of guidelines and studies (2016–2025; PubMed, Google Scholar) was conducted using keywords related to peripheral administration, cannula selection (gauge/site), material compatibility (polypropylene [PP], polyethylene [PE], polyurethane [PUR], polyvinyl chloride [PVC]), and light protection requirements.

Results. The incidence of extravasation during norepinephrine infusion via a peripheral intravenous line is low (e.g., 0.035% in perioperative populations; 1.7–3.2% in other cohorts) when using 18–20 G cannulas placed proximal to the wrist and with close monitoring. Nitroglycerin undergoes significant sorption to PVC and PUR (preferred sets for infusion of nitroglycerin made of PP/PE). Catecholamines require light protection during intravenous continous infusion. Large-bore cannulas enhance fluid resuscitation efficiency.

Conclusions. In the absence of central venous access, complication risk can be minimized by appropriate cannula size and site selection, proper drug dilution and infusion rates, and use of compatible infusion set materials. Development of local protocols and further clinical studies are warranted. For peripheral administration of catecholamines, the safest approach is to select a cannula of ≤ 20 G and ≥ 1.1 mm inner diameter in adults, and ≤ 24 G and ≥ 0.7 mm in pediatric patients, with placement proximal to the wrist on the upper extremity. This review highlights the need for close collaboration among multidisciplinary care teams—including physicians, pharmacists, and nurses—to ensure optimal management of critically ill patients in the intensive care unit.

Keywords: cardiogenic shock, catecholamines, peripheral line, central line.

© Farm Pol, 2025, 81(2): 113–122