Management of Vasopressor Extravasation Injuries

by Joseph Esherick, M.D., FAAFP, FHM

Peripheral vasopressor infusions are generally safe at low-moderate doses and for short durations, but you must watch the patient carefully for extravasation that can cause serious tissue injury.

Traditionally, central lines were placed for administration of vasopressor infusions at any rate. We now know that peripheral administration of vasopressor medications can be done safely.  The best studied vasopressors for peripheral administration are norepinephrine and phenylephrine. Most studies suggest that both norepinephrine and phenylephrine can be safely administered for up to 24 hours at doses at least up to 0.1 mcg/kg/min. It is generally recommended that central lines are placed for vasopressor infusion rates above 0.1 mcg/kg/min or if patients have escalating vasopressor requirements during the first 6 hours of shock management after adequate volume resuscitation.

Most peripheral IV were placed in the forearm or antecubital fossa and should be at least 18 guage peripheral IVs. The extravasation risk is 2-5% with few patients requiring antidote administration or surgical intervention. 

Vasopressor extravasation can cause tissue ischemia and necrosis. Risk factors for tissue ischemia include pre-existing vasculopathy, hypotension, diabetic neuropathy, Raynaud disease, advanced age and volume of vasopressor infiltrated.

The management of all vasopressor extravasations include:

  • Stopping vasopressor infusion
  • Discontinuing peripheral IV
  • Elevate the affected limb
  • Warm compresses to affected area for 15 minutes 4x/day
  • For high-risk extravasations, use intradermal phentolamine 5-10 mg mixed in 10 mL sterile saline injected into the affected area

References:

  1. Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. J Hosp Med. 2015 Sep;10(9):581-585.
  2. Datar S, Gutierrez E, Schertz A, Vachharajani V. Safety of phenylephrine infusion through peripheral intravenous catheter in the neurological intensive care unit. J Intensive Care Med. 2018 Oct;33(10):589-592.
  3. Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents J Intensive Care Med. 2019 Jan;34(1):26-33
  4. Reynolds P. M. et al.  Management of Extravasation Injuries: A Focused Evaluation of Noncytotoxic Medications. Pharmacotherapy 2014;34(6):617--632