Episode 240: What to do with norepinephrine extravasation

In this episode, I’ll discuss what to do when norepinephrine extravasates.

Central line access is often preferred for vasopressor administration due to the risk of extravasation. Extravasation of a vasopressor such as norepinephrine can cause tissue necrosis and ultimately, the loss of a limb due to local vasoconstriction.

The terms extravasation and infiltration are often interchanged. Both terms refer to the accidental extravenous administration of medication. The term infiltration is meant for when the medication in the extravenous space is not expected to cause tissue damage. The term extravasation is meant for when the medication in the extravenous space is a known vesicant and may cause tissue damage.

What should you do if a nurse notifies you that a norepinephrine infusion has extravasated?

First, have the nurse stop the infusion, but do not remove the IV catheter just yet. The catheter should be aspirated, in order to attempt to remove some of the remaining norepinephrine.

Second, If your institution has an IV team of nurses specially trained for dealing with IV therapy complications, have them paged.

Resist the urge to apply a cold compress. Cold is often used during extravasation to vasoconstrict and stop the spread of the vesicant. However, in the event of norepinephrine (or another vasopressor) extravasation, the combined vasoconstriction from the drug and cold compress may worsen the tissue damage.

Once the nurse has started to implement these non-pharmacologic interventions, the pharmacist should immediately obtain phentolamine and bring it to the bedside.

Phentolamine blocks alpha-adrenergic receptors to directly antagonize the effects of norepinephrine. There was a brief period recently where phentolamine was unavailable. I discussed alternatives to phentolamine back in episode 6.

Depending on the size of the extravasation, bring 5 to 10 mg of phentolamine to the bedside. This will need to be reconstituted, and further diluted to 0.5 mg/mL in normal saline.

Treatment of the extravasation will involve the nurse administering the phentolamine intradermally around the site of the extravasation. Most nurses will prefer that the phentolamine is divided into several syringes each with a 25 gauge needle on them so that the same needle will not have to be used to penetrate the skin more than once.

You’ll want to give the phentolamine as soon as possible, although it may be effective as long as 12 hours after the extravasation.

If the patient is still having symptoms or signs of local vasoconstriction (pain, blanching of the skin, etc…) the phentolamine dose may be repeated. There is no data on the ideal time to wait for improvement or to re-dose. In my experience, phentolamine resolves the extravasation symptoms in a few hours.

Other non-pharmacologic treatments such as elevating the extremity and application of warm, dry compresses are thought to be helpful but are without supporting data.

Throughout the treatment of the extravasation, don’t forget to keep an eye on the patient’s blood pressure. Additional IV sites or central line placement may need to temporarily take priority if the patient’s blood pressure drops due to the norepinephrine infusion being stopped.

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