Administration of Norepinephrine (Levophed) Through Humeral Head IO
Yes, norepinephrine (Levophed) can be administered through a humeral head intraosseous (IO) line, and the humeral site may actually provide better flow rates compared to other IO sites.
IO Access for Medication Administration
- IO access is a valid alternative when IV access is not readily available during resuscitation, and all ACLS medications can be administered through this route 1.
- The humeral head is a suitable site for IO placement with high insertion success rates comparable to tibial sites 2.
- When establishing vascular access during cardiac arrest, the primary purpose is to provide drug therapy, and this should be performed without interrupting chest compressions 1.
Humeral Head IO Flow Rates
- The humeral head IO site provides significantly higher flow rates compared to the tibial IO site, with studies showing:
- Higher flow rates at the humeral site may be beneficial when administering vasoactive medications like norepinephrine that require precise dosing 4.
Norepinephrine Administration Considerations
- Norepinephrine is indicated for treatment of severe hypotension (e.g., systolic blood pressure <70 mmHg) and low total peripheral resistance 1.
- The typical starting dose is 0.1-0.5 mcg/kg/min (7-35 mcg/min in a 70-kg adult), which can be titrated to effect 1.
- Vasopressors like norepinephrine are recommended only when the combination of an inotropic agent and fluid challenge fails to restore adequate blood pressure and organ perfusion 1.
Safety Considerations
- Extravasation of norepinephrine can cause tissue necrosis, so proper IO needle placement confirmation is essential 1.
- If extravasation occurs, infiltrate 5-10 mg of phentolamine diluted in 10-15 mL of saline into the site as soon as possible to prevent tissue damage 1.
- While central line administration is traditionally preferred for norepinephrine, studies have shown that peripheral administration can be safe with proper monitoring protocols 5, 6.
Practical Administration Tips
- Confirm proper IO needle placement before administering norepinephrine 2.
- Use pressure bag infusion to optimize flow rates through the IO line, as studies show significantly faster flow rates with pressure bag infusion compared to gravity infusion 2.
- Monitor the IO site frequently for signs of extravasation or displacement 6.
- Be prepared to transition to central venous access if prolonged vasopressor therapy is anticipated 6.
Conclusion
The humeral head IO site is an appropriate route for norepinephrine administration during emergency situations when vascular access is limited. The higher flow rates achieved at this site compared to tibial IO make it particularly suitable for vasoactive medication delivery when time is critical 3, 4.