Peripheral Vasopressors and VASOPRESSOR EXTRAVASATION

Why Use Peripheral Vasopressors?

Vasopressors (e.g., norepinephrine, epinephrine, dopamine, vasopressin) are used in shock to increase blood pressure and improve perfusion to vital organs. Traditionally, these were given only through a central line due to risks of extravasation (leakage into surrounding tissue), which can cause skin necrosis, limb ischemia, or compartment syndrome.

However, inserting a central line takes time, and every hour of delay in vasopressor initiation increases mortality by 2%. So, in emergency settings, using a peripheral IV (PIV) for vasopressors can save lives.

The Surviving Sepsis Campaign now recommends starting vasopressors peripherally if central access is not immediately available to prevent worsening hypotension and organ failure.

Key Risks of Peripheral Vasopressors

• Extravasation: Leakage of the drug into surrounding tissues, leading to necrosis.
• Limb Ischemia: Severe vasoconstriction reducing blood flow.
• Hypotension during transition: Switching from peripheral to central access can cause BP drops. Switching lines without overlapping infusion may transiently reduce drug delivery

How Common Are These Complications?

• Extravasation rates: ~1.8% in adults, comparable to central line complications (pneumothorax, bloodstream infections, deep vein thrombosis).
• Severe tissue injury is rare, especially with proper precautions.

Best Practices for Safe Peripheral Vasopressor Use

1?? Choose the Right IV Site

• Proximal veins are safer than distal veins. Best sites: Antecubital fossa (cephalic or basilic vein), upper arm.
• Avoid: Hand, wrist, and small distal veins (higher extravasation risk).
• Use ultrasound guidance to ensure proper placement.

2?? Use a Large IV Catheter

• 18G or larger preferred (≤ 20G has higher complication rates).
• Larger catheters reduce infiltration risk and allow better flow.

3?? Use Dilute Vasopressor Solutions

• Lower concentrations reduce the risk of severe local vasoconstriction.
• Example: Norepinephrine 20 mcg/mL has low complication rates.

4?? Monitor the IV Site Frequently

• Regular assessments every 1-2 hours.
• Look for pain, swelling, pallor, or skin changes.
• Stop infusion immediately if extravasation occurs.

5?? Limit Infusion Duration

• <24 hours recommended (higher risk of complications beyond this).
• If ongoing vasopressors are needed, transition to a central line ASAP.

6?? Always Have Backup IV Access

• Maintain at least two working IVs in case one fails.
• This ensures a smooth transition if central access is needed.

What If Extravasation Happens?

Recognizing Extravasation

Symptoms:

• Pain, tightness, tingling, burning, itching

Exam Findings:

• Swelling, redness, blisters, ulceration, necrosis
• Unexplained decrease in IV flow rate (early warning sign)

Immediate Management (First Steps)

?? STOP the infusion immediately—do NOT flush the line.

?? Leave the catheter in place and aspirate as much drug as possible with a syringe.

?? Elevate the limb to reduce swelling and discomfort.

?? Apply warm compresses (20 minutes every 4–6 hours for 1–2 days).

?? Restart vasopressor infusion at a new IV site (preferably more proximal).

?? Small extravasations: Supportive care and close observation may be enough.

Large Volume Extravasation or Severe Cases

Some cases require escalation of care:

?? Medications:

• Terbutaline (ordered through EPIC as "Extravasation Management Dosing")
• Phentolamine (alpha-blocker): 5–10 mg diluted in 5-10 cc saline and subcutaneously around the affected area using the extravasated IV line.
• Nitroglycerin paste: Topical application to improve local blood flow
• Hyaluronidase: Facilitates drug dispersion

?? Indications for Surgical Consultation: ?? Infection or abscess formation ?? Progression of tissue damage despite conservative treatment ?? Clinical deterioration (ischemia, necrosis, or persistent injury)

Documentation & Follow-Up

?? Always document the extravasation event and interventions taken.

?? Monitor the site closely for delayed complications.

Key Takeaways

? Start peripheral vasopressors if central access is delayed—it improves survival.

? Use large-bore IVs (18G or larger) in proximal arm veins for safety.

? Dilute concentrations reduce extravasation risk.

? Monitor frequently.

? Know how to manage extravasation—quick action prevents tissue damage.