What is the best management approach for inadvertent tissue extravasation of intravenous (IV) dopamine?

Management of Inadvertent Tissue Extravasation of Intravenous Dopamine

Local infiltration of phentolamine is the best management approach for inadvertent tissue extravasation of intravenous dopamine. 1

Mechanism of Dopamine Extravasation Injury

Dopamine is a vasoactive medication that can cause severe tissue injury when extravasated into surrounding tissues. The mechanism of injury involves:

1. Local vasoconstriction due to alpha-adrenergic effects
2. Tissue ischemia leading to potential necrosis
3. Severe skin injury that may require surgical intervention if not promptly treated

Evidence-Based Management

The American Academy of Pediatrics guidelines specifically recommend phentolamine for dopamine extravasation. The recommended dose is 0.1-0.2 mg/kg (up to 10 mg) diluted in 10 mL of 0.9% sodium chloride injected intradermally at the extravasation site 1. This treatment counteracts the dermal vasoconstriction caused by dopamine.

The FDA drug label for dopamine also acknowledges that extravasation can result in severe skin injury and notes that phentolamine injected intradermally at the extravasation site may be helpful for counteracting dermal vasoconstriction 2.

Management Algorithm

1. Immediate recognition and intervention:

   • Stop the dopamine infusion immediately
   • Elevate the affected limb if possible

2. Phentolamine administration:

   • Prepare phentolamine: 0.1-0.2 mg/kg (maximum 10 mg) diluted in 10 mL of normal saline
   • Inject intradermally around the periphery of the extravasation site
   • Administer as soon as possible after extravasation is detected

3. Monitoring and follow-up:

   • Assess the site frequently for signs of improved perfusion
   • Monitor for resolution of blanching and return of normal skin color
   • Document the event and intervention

Alternative Options

While phentolamine is the first-line treatment, other options have been studied:

• Topical nitroglycerin has shown some efficacy in case reports 3, but has less supporting evidence than phentolamine
• Terbutaline has been suggested as an alternative when phentolamine is unavailable 4

Prevention Strategies

To prevent dopamine extravasation:

• Use central venous access whenever possible for dopamine infusion
• If peripheral administration is necessary, use a large vein (preferably antecubital fossa)
• Use a long intravenous catheter (at least 20 gauge or larger)
• Frequently inspect the IV site for signs of extravasation 5

Common Pitfalls to Avoid

1. Delayed recognition: Tissue damage can progress rapidly; immediate intervention is crucial
2. Inadequate treatment: Simply stopping the infusion without antidote administration is insufficient
3. Misconception about dose-related risk: Even low-dose dopamine infusions can cause severe extravasation injury 5
4. Using ice: Ice may worsen vasoconstriction and is not recommended
5. Relying only on topical treatments: Local infiltration with phentolamine is more effective than topical treatments alone

Phentolamine works by directly antagonizing the alpha-adrenergic effects of dopamine, making it the most effective treatment for reversing the vasoconstriction and preventing tissue necrosis 6.