Extravasation
10 mg of Phentolamine can be added to each liter of solution containing norepinephrine. The pressor effect of norepinephrine is not affected - Scott Weingart MD
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Treatment of Shock and Prevention of Ischemic Necrosis with Levarterenol-Phentolamine Mixtures
ISCHEMIC NECROSIS resulting from accidental extravasation of levarterenol (Levophed) in patients in shock can be prevented by local injection of 5 or 10 mg. of the anti-adrenergic drug phentolamine (Regitine). This method is not effective when vasoconstriction has existed for several hours and irreversible tissue damage has occurred.
Preliminary observations suggest that inmediate protection can be secured by adding phentolamine to the flask of levarterenol...
Resources
Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine
Vasopressor extravasation is a rare adverse drug reaction that can lead to tissue damage, ischemia, and necrosis of the affected area when vasopressors are administered peripherally. Phentolamine, a nonselective, reversible alpha antagonist, is the current standard treatment for this adverse reaction, but it is often unavailable for use.
Peripheral Pressors: 6 Pearls to Not F*#k Up the Arm
Traditionally, vasopressor infusions have been done through central venous catheters (CVCs) due to the hypothetical risk of extravasation injury to extremities when given through peripheral IVs. The documented risk of extravasation from peripheral pressors is 3 – 6%. Hypothetically, the extravasation rate can be further reduced.
Peripheral Vasopressor Infusions and Extravasation
10 mg of Phentolamine can be added to each liter of solution containing norepinephrine. The pressor effect of norepinephrine is not affected.
A Potent Medication Administered in a Not So Viable Route
In summary, when faced with a patient in shock refractory to adequate fluid resuscitation, the administration of vasopressors can be lifesaving. These medications can safely be administered through peripheral IVs if the IV is in a proximal location such as the antecubital fossa, has good blood return, and flushes easily. Such peripheral infusion can allow the rapid stabilization of the patient and facilitate the orderly insertion of a central line in a stable environment. The site of vasopressor infusion should be monitored regularly for signs of complications, and the duration of vasopressor infusion should be kept to no more than 2 hours. If extravasation or ischemic complications occur, they can be treated with administration of phentolamine and nitroglycerine paste to the area.
What to do with norepinephrine extravasation
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 Shock and Prevention of Ischemic Necrosis with Levarterenol-Phentolamine Mixtures
Our present practice is to add 5 mg. of phentolamine to each liter of levarterenol solution.
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