Safety of Peripheral Vasoactive Drug Administration in Prehospital and Retrieval Medicine (SPOTLESS-2): A Prospective Observational Cohort Study.
Greaves et al. · Academic Emergency Medicine · 2026
Prospective cohort · Observational study · n = 468
Vasopressors · Prehospital retrieval medicine · Australia
Written by: Stephen Colman
● Prospective ● Broad patient cohort ● Single centre ● Observational ● Selection bias ● Data Capture
Previously, the administration of adrenaline and noradrenaline has been through central venous lines due to safety concerns over peripheral administration. This study demonstrates that peripheral administration of these medications is safe in the prehospital retrieval setting.
Vasopressors are a cornerstone therapy in critical care retrieval (CCR). Previous South African prehospital literature demonstrated that adrenaline was the predominant vasoactive agent administered during advanced life support transfers at a public ambulance service in the Western Cape Province.
The SPOTLESS-2 study was conducted at a single aeromedical service in Queensland, Australia. Both electronic and paper-based patient care reports were prospectively collected between April 2022 and August 2023, and 468 cases were included for review. The study aimed to establish the safety of peripherally administered adrenaline and noradrenaline.
Vasopressor concentrations of 3 mg in 50 ml (60 µ/ml) were administered by a syringe driver in all cases. Most patients (72.4%) received noradrenaline, with a median dose of 0.1 µg/kg/min, and 0.13 µg/kg/min for adrenaline. The remaining patients either received adrenaline (21.4%) or a combination of adrenaline and noradrenaline (6.2%).
The anterior cubital fossa (ACF) was the most common infusion site (78%), and septic shock was the most common indication for vasopressor administration (48.2%). Over a quarter of patients received push-dose vasoactives in addition to their infusions (26.4%). Adrenaline was the most commonly administered push-dose vasopressor administered (49.2%), followed by metaraminol (48.3%). Patients receiving adrenaline via continuous infusion more commonly needed additional push-doses.
had no adverse events with peripheral infusion.
had minor technical issues with drug delivery.
had minor complications affecting patient care.
required conversion to central venous access (due to provider preference).
Catheter kinking or line pressure alarms were the most common issue (2.7%), and infiltration or cannula dislodgment occurred 3 times (0.6%). Larger cannula size and non-ACF sites may be associated with fewer complications. There were no tissue complications at 24-hour follow-up. Selection bias may influence these results, as patients who already had central lines were not included, which may exclude a sicker population on higher-dose infusions.
To date, this is the largest prospective study evaluating peripheral vasopressors in the prehospital retrieval medicine (PHRM) setting. Based on this data, the authors suggest that peripheral adrenaline and noradrenaline can be safely administered in PHRM settings, with a low risk of complications.
This study demonstrates that peripheral vasopressors can be safely administered in the PHRM setting. No tissue complications were recorded in the 24-hour follow-up period. All major complications (0.8%) were in transit conversion to central access, due to physician preference not failure of peripheral drug delivery.
This is relevant to South African prehospital and CCR settings, where patients requiring vasopressor support are likely to receive peripheral adrenaline by continuous infusion.
Further, this study uniquely contributes safety data for infusion concentrations of up to 60µg/ml (3 mg in 50 ml), which is three times the strength of infusion preparations recommended in the Clinical Decision Support Tool. Select aeromedical services utilise the same infusion preparation of adrenaline in South Africa, which makes this evidence directly applicable to local practice. Authors reported high usage of push-dose vasopressors and attributed this practice to initial stabilisation attempts while continuous infusions were being set up.
Similar research should be undertaken in South Africa, where CCR is predominantly paramedic-led, often without the option of conversion to central venous access during transport.
