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• W4387248663 abstract "SESSION TITLE: Critical Complications of Treatment SESSION TYPE: Case Reports PRESENTED ON: 10/11/2023 08:30 am - 09:30 am INTRODUCTION: Infusion of norepinephrine (NE) via peripheral intravenous access (PIVA) has been shown to be both feasible and safe. Extravasation though PIVA, although uncommon, may be potentially harmful. We report a case of NE extravasation through PIVA that resulted in severe limb ischemia and our management of this complication. CASE PRESENTATION: A 64-year-old male was hospitalized for upper gastrointestinal bleeding with hypotension and a systolic blood pressure of 50 mmHg in the Emergency Department (ED). A 2 cm long, 18-gauge PIVA was in placed in the right basilic arm vein just proximal to the antecubital fossa under ultrasound guidance (UG). The PIVA was secured with a transparent film dressing and NE infusion was initiated to maintain systolic blood pressure simultaneous with volume resuscitation and red cell transfusion. The MICU team was contacted 20 minutes after the norepinephrine infusion was started because the patient's right arm distal to the PIVA site had become mottled and cool with concern that the PIVA infusion had extravasated. Phentolamine 5 mg was injected locally and 5 cm of 2% nitroglycerin ointment was applied by the MICU team in the ED per standard MICU NE extravasation protocol. Upon arrival to the MICU, the mottling had become severe with absent radial and ulnar arterial pulses on physical exam confirmed by absence of color flow Doppler signal. There was swelling and tenseness in the area of the distal basilic vein and there was complete absence of capillary refill upon compression of the right hand nail beds. This raised concern for arterial ischemia with potential limb loss due to NE extravasation. In response, a 10 cm long 20 gauge arterial catheter was inserted into the right brachial artery under US guidance followed by intra-arterial injection of 2.5 mg of verapamil and 0.2 mg of nitroglycerin. This resulted in prompt improvement of the physical appearance of the arm, and within 30 minutes the abnormal physical examination findings had disappeared completely with return of palpable pulses and color flow Doppler to the affected arteries. DISCUSSION: We describe limb threatening ischemia as a complication of NE infusion via PIVA. Our standard method of treating this form of extravasation was not effective. This prompted escalation to use of intra-arterial vasodilators. A contributory factor to the extravasation was probably that the PIVA was inserted in such a manner that arm flexion caused dislodgment. CONCLUSIONS: NE extravasation via PIVA is uncommon but may result in potentially catastrophic limb ischemia. If application of a local antidote (local alpha blocker tissue injection and topical nitroglycerin ointment) is not sufficient, then the MICU team should consider the option of direct intra-arterial injection of vasodilators into the supply artery. This report underlines the importance of following a standard safety protocol for safe infusion of NE via PIVA. REFERENCE #1: Greenstein YY, Koenig SJ, Mayo PH, Narasimhan MA. Serious Adult Intraosseous Catheter Complication and Review of the Literature. Crit Care Med, 2016:44(9); e904–e90 REFERENCE #2: Cardenas-Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH. Safety of peripheral intravenous administration of vasoactive medication. J of Hosp Med. 2015:10(9); 581–58 REFERENCE #3: Sandoval Y, Bell MR, Gulati R. Transradial Artery Access Complications. Circulation. Cardiovascular interventions. 2019:12(11);e007386 DISCLOSURES: No relevant relationships by Paul Mayo No relevant relationships by Henry Mayo-Malasky" @default.
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• W4387248663 title "A SERIOUS COMPLICATION OF NOREPINEPHRINE INFUSION VIA PERIPHERAL INTRAVENOUS ACCESS WITH SUCCESSFUL TREATMENT" @default.
• W4387248663 doi "https://doi.org/10.1016/j.chest.2023.07.1347" @default.
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