Vasopressor Infusion via Peripheral vs Central Access in patients with shock.

Common treatment applied to both groups The VPI will be initiated via the PIVC in both groups at a time chosen by the treating clinician as per standard practice (it is standard practice for all patients with shock to have at least one PIVC inserted as soon as possible in Australian Emergency Departments) All other treatments for the underlying condition that has necessitated VPI (such as antibiotics, source control procedures, fluid therapy) will be at the discretion of the treating clinician Peripheral Vasopressor group (Late Central group) – usual care (as defined below) plus: Peripheral Intravenous Canula (PIVC), 18-gauge preferred Delayed insertion of central venous line (CVC) – A CVC is not to be inserted for at least 12 hours from randomisation. A CVC can be inserted earlier than 12 hours if required for the following reasons: Noradrenaline-equivalent dose greater than or equal to 0.2mcg/kg/min Need for irritant medications/infusions that cannot be administered via a PIVC Failure of drug delivery via PIVC Complications of PIVC including extravasation of Vasopressor Infusion (VPI), or tissue necrosis The PIVC/CVC will be inserted by ED or ICU doctors and monitored by ED and ICU nurses The insertion of the PIVC is anticipated to take 5 minutes, delayed insertion of the CVC is anticipated to take approximately 20 minutes Early Central VPI group - usual care plus Patients in the Early Central group will have a CVC inserted within 4 hours of randomisation Usual care includes: a combination of cardiopulmonary resuscitation, fluid resuscitation, vasopressors given as bolus &/or infusion, source control including surgical intervention, antibiotics as well as investigations etc. and in accordance with standard medical practice. A VPI includes any of the following medications – Noradrenaline, Adrenaline, Metaraminol, Phenylephrine and Vasopressin.