What is the treatment for Levophed (norepinephrine) infiltration?

Treatment of Levophed (Norepinephrine) Infiltration

The immediate treatment for Levophed (norepinephrine) infiltration is phentolamine injection at the extravasation site to prevent tissue necrosis.

Pathophysiology of Levophed Extravasation

Levophed (norepinephrine) is a potent vasopressor that can cause significant tissue damage when it infiltrates into surrounding tissue during peripheral administration. The alpha-adrenergic effects cause intense vasoconstriction, which can lead to:

• Tissue ischemia
• Necrosis
• Skin sloughing
• Permanent tissue damage

Management Protocol for Levophed Infiltration

Immediate Actions

1. Stop the infusion immediately
2. Administer phentolamine (alpha-adrenergic antagonist):
   • Dilute 5-10 mg phentolamine in 10 mL of normal saline
   • Inject intradermally into the extravasation site
   • Multiple small injections around the periphery of the affected area
   • Administer within 12 hours of extravasation for best results 1, 2

Additional Measures

• Elevate the affected extremity
• Apply warm compresses to promote vasodilation
• Monitor the site closely for signs of tissue recovery
• Document the event, including time of detection, estimated amount of infiltrated drug, and interventions

Prevention Strategies

1. Preferred Administration:

   • Use central venous access whenever possible 3
   • When using peripheral IV, choose a large vein with good blood flow

2. Monitoring:

   • Frequent inspection of IV site (every 1-2 hours)
   • Check for signs of infiltration: swelling, pallor, coolness, pain 4
   • Use transparent dressings to facilitate visualization

3. Administration Technique:

   • Secure IV catheter properly to prevent dislodgement
   • Avoid catheter tie-in techniques that promote stasis 3
   • Use an infusion pump with pressure monitoring capabilities

Evidence for Phentolamine Use

Phentolamine is highly effective in preventing tissue necrosis after norepinephrine extravasation due to its alpha-adrenergic blocking properties 2, 5. Studies have demonstrated that:

• Phentolamine effectively reverses the vasoconstriction caused by norepinephrine
• Early administration (within 12 hours) provides the best outcomes
• The mechanism involves counteracting the alpha-adrenergic effects that cause vasoconstriction 2

Special Considerations

• Timing is critical: The sooner phentolamine is administered after extravasation, the better the outcome
• Alternative agents: If phentolamine is unavailable, consider terbutaline or nitroglycerin paste as alternatives, though evidence for these is less robust
• Documentation: Carefully document the event, interventions, and outcomes for quality improvement and risk management purposes

Pitfalls to Avoid

• Delayed recognition: Regular monitoring of the IV site is essential to detect infiltration early
• Inadequate treatment: Ensure complete coverage of the affected area with phentolamine
• Underestimating severity: Even small amounts of infiltrated norepinephrine can cause significant tissue damage
• Continued use of damaged site: Never reuse the infiltrated vein for subsequent infusions

By following this protocol promptly when Levophed infiltration occurs, you can significantly reduce the risk of severe tissue damage and necrosis that might otherwise require surgical debridement or result in permanent tissue loss.