Extravasation of pressors

Q; In case of extravasation of intravenous pressor in ICU, all of the following can be used as an antidote except?

A) Phentolamine (injection locally)
B) Nitroglycerin (topical)
C) Terbutaline (inject locally)
D) Clonidine (topical)


Answer: D

 Extravasation of all intravenous infusions is an inherent risk. In the case of extravasation of VASOpressors following sequential steps should be taken before giving an antidote

1. Immediately stop the infusion 
2. Disconnect the infusion but leave cannula or needle in place 
3. Gently aspirate the extravasated solution 
4. Do NOT flush the line 
5. Remove the needle or cannula (now)
6. Elevate the extremity. 


Phentolamine is the first choice in vasopressor extravasation. Depending on the area of extravasation, 5 to 10 mg of phentolamine should be diluted in 10 to 20 mL NS and administer by injecting locally at the extravasation site as soon as possible. It can be applied up to 12 hours of the accident. 

 Alternatively, Nitroglycerin topical 2% ointment in a 1-inch strip can be applied to the site of ischemia and can be continued every 8 hours until the situation seems resolved.

Another option is to dilute 1 mg of terbutaline in 10 mL NS and inject locally at the extravasation site. 

Clonidine is an alpha-2 adrenergic agonist and has no role in the treatment.


#toxicology


References:

1.  Plum, M., & Moukhachen, O. (2017). Alternative Pharmacological Management of Vasopressor Extravasation in the Absence of Phentolamine. P & T : a peer-reviewed journal for formulary management, 42(9), 581-592. 

2. Reynolds PM, Maclaren R, Mueller SW, et al. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632