What are the potential consequences of administering vasopressin or norepinephrine (Levophed) through the same peripheral intravenous (IV) line in the lower arm that has a blood pressure (BP) cuff on the upper arm?

From the Guidelines

Administering vasopressin or norepinephrine through a peripheral IV in the lower arm while using a blood pressure cuff on the upper arm of the same extremity can lead to serious complications, including tissue ischemia, extravasation injuries, and even tissue necrosis requiring amputation in severe cases. When the BP cuff inflates, it temporarily stops blood flow to the area below it, which can cause the vasopressor to remain concentrated in the tissue of the lower arm, resulting in reduced drug delivery to the systemic circulation and potential tissue damage in the arm 1. Vasopressors like norepinephrine and vasopressin cause intense vasoconstriction, and when concentrated in peripheral tissues, they can lead to severe side effects, as noted in a recent clinical practice update 1.

Some key points to consider when administering vasopressors include:

• Always administer vasopressors through central lines when possible
• If using a peripheral line temporarily, ensure it's in a large vein with no obstructions like BP cuffs proximal to the insertion site
• If you must monitor blood pressure and give vasopressors peripherally, use different extremities for these purposes
• Start with the lowest dose and gradually titrate upward to minimize the risks of ischemic side effects, as recommended in recent clinical guidelines 1.

Proper technique for BP measurements is also crucial, as outlined in the 2019 AHA/ACC clinical performance and quality measures for adults with high blood pressure, which includes using a validated BP measurement device, supporting the patient's arm, and positioning the middle of the cuff on the patient's upper arm at the level of the right atrium 1. However, the primary concern when administering vasopressors is to avoid complications related to their potent vasoconstrictive effects.

From the FDA Drug Label

LEVOPHED should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed If LEVOPHED is continuously administered to maintain blood pressure in the absence of blood volume replacement, the following may occur: severe peripheral and visceral vasoconstriction, decreased renal perfusion and urine output, poor systemic blood flow despite "normal" blood pressure, tissue hypoxia, and lactate acidosis Overdosage with LEVOPHED may result in headache, severe hypertension, reflex bradycardia, marked increase in peripheral resistance, and decreased cardiac output.

The administration of vasopressin or norepinephrine through the same peripheral IV in the lower arm that has a BP cuff to the upper arm may lead to:

• Severe peripheral vasoconstriction due to the potent vasoconstrictive effects of these medications
• Decreased blood flow to the arm, which may be exacerbated by the BP cuff
• Tissue hypoxia and potentially lactate acidosis if the decreased blood flow is severe
• Severe hypertension and reflex bradycardia in the event of overdosage 2 2 It is essential to exercise caution when administering these medications, especially in patients with pre-existing vascular conditions or those who are hypotensive due to blood volume deficits.

From the Research

Administration of Vasopressin or Norepinephrine through Peripheral IV

• The administration of vasopressin or norepinephrine through a peripheral intravenous (IV) line in the lower arm with a blood pressure (BP) cuff on the upper arm is a topic of interest in medical research 3, 4, 5, 6, 7.
• Studies have shown that the use of peripheral IV lines for administering vasoactive medications, including norepinephrine and vasopressin, is feasible and safe in certain clinical settings 3, 4, 5, 6, 7.

Risks and Complications

• One of the potential risks associated with administering vasoactive medications through a peripheral IV line is extravasation, which can lead to tissue injury 3, 4, 5.
• However, the incidence of extravasation is relatively low, ranging from 2% to 3.4% in various studies 3, 4, 5.
• In most cases, extravasation can be managed conservatively or with vasodilatory medications, and serious complications are rare 3, 4, 5.

Protocol Development and Implementation

• The development and implementation of protocols for peripheral administration of vasopressors can help minimize the risks associated with this practice 5, 6, 7.
• These protocols typically include guidelines for patient selection, IV line placement, medication dosing, and monitoring for adverse events 5, 6, 7.
• Studies have shown that the use of these protocols can reduce the need for central venous catheter placement and decrease the risk of central line-associated bloodstream infections 6, 7.

Clinical Implications

• The administration of vasopressin or norepinephrine through a peripheral IV line in the lower arm with a BP cuff on the upper arm may be a viable option in certain clinical situations 3, 4, 5, 6, 7.
• However, clinicians should carefully evaluate the potential risks and benefits of this practice and develop strategies to minimize complications 3, 4, 5, 6, 7.