Vasoconstrictor extravasation

Q: 44 years old female is admitted to ICU with urosepsis. Norepinephrine (NE) ion is started in Emergency Department (ED) via peripheral IV. On arrival to ICU, it was noted that peripheral IV was not functional, and there was a significant amount of NE extravasated in underlying tissues. What is your next step?

Answer: Apply PHENTOLAMINE

PHENTOLAMINE is the antidote for vasoconstrictor extravasation in skin and tissues (dopamine, epinephrine, or norepinephrine). Infiltrate 5-15 mg of PHENTOLAMINE in 10 ml of normal saline into the area of extravasation as soon as possible. Treatment may be applied and effective up to 12 hours post extravasation of vasoconstrictor. Patient might develop transient hypotension post phentolamine application but responds well to fluid bolus.

Mechanism of action: Phentolamine is a nonspecific alpha-adrenergic blocking agent that inhibits vasoconstriction and improves blood circulation through the affected area.

If phentolamine is unavailable, a combination of subcutaneous terbutaline, a selective beta2 agonist, and topical nitroglycerin can be applied.

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References: 

1. Bey D, El-Chaar GM, Bierman F, Valderrama E. The use of phentolamine in the prevention of dopamine-induced tissue extravasation. J Crit Care. 1998 Mar;13(1):13-20. doi: 10.1016/s0883-9441(98)90024-7. PMID: 9556122.

2. Plum M, Moukhachen O. Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine. P T. 2017 Sep;42(9):581-592. PMID: 28890646; PMCID: PMC5565133.