What medication can be given if norepinephrine (norepi) extravasates?

Management of Norepinephrine Extravasation

Phentolamine is the definitive antidote for norepinephrine extravasation—inject 5-10 mg diluted in 10-15 mL of saline intradermally into the extravasation site as soon as possible, ideally within 12 hours. 1

Immediate Treatment Protocol

For adults: Infiltrate 5-10 mg of phentolamine mesylate diluted in 10-15 mL of 0.9% sodium chloride solution directly into the area of extravasation using multiple small aliquots at various sites around the affected tissue 2, 1, 3

For pediatric patients: Use 0.1-0.2 mg/kg of phentolamine (maximum 10 mg) diluted in 10 mL of 0.9% sodium chloride, injected intradermally at the extravasation site 2

Mechanism and Timing

• Phentolamine works as a potent alpha-adrenergic receptor antagonist, reversing the intense vasoconstriction caused by norepinephrine extravasation 4

• The FDA label specifies administration within 12 hours of extravasation for optimal tissue salvage, though earlier intervention yields better outcomes 1

• Expect immediate visible changes: the affected area should rapidly transition from a "blanched" appearance to a "pink" color within minutes of phentolamine injection, indicating restored perfusion 4

Administration Technique

• Inject the diluted phentolamine solution subcutaneously in small aliquots distributed throughout the entire extravasation zone, not just at a single point 4

• Multiple injection sites ensure adequate distribution of the antidote throughout all affected tissue 4

• Instantaneous erythematous macules at injection sites are expected and typically resolve within 24-36 hours 4

Preventive Strategy

• For high-risk situations, 10 mg of phentolamine can be added prophylactically to each liter of norepinephrine solution without affecting its pressor effect 1

Clinical Context

• The actual risk of clinically significant extravasation with peripheral norepinephrine is extremely low (0.035% or approximately 3-4 per 10,000 patients), with zero cases requiring surgical intervention in a large multicenter study of 14,385 patients 5

• Despite the low incidence, when extravasation occurs without treatment, it can progress from dermal necrosis to ulceration and require prolonged healing 4

• Prompt phentolamine administration prevents progression to tissue necrosis and surgical debridement 4, 3

Critical Pitfall to Avoid

• Do not delay phentolamine administration—the 12-hour window represents the outer limit, but immediate treatment (within minutes to hours) provides superior tissue salvage 1, 4