184: THE INJECTION OF INTRA-ARTERIAL VASODILATOR FOR THE TREATMENT OF VASOPRESSOR EXTRAVASATION

Abstract

Introduction: We described a case where vasopressor extravasation occurred and was mitigated immediately utilizing two novel techniques. This discussion highlights the importance of learning and understanding the rapid execution of treatment modalities in cases of subcutaneous extravasation of vasopressors. Description: A 67-year-old female with coronary artery disease, hypertension, anemia, and recurrent upper gastrointestinal bleeding presented to the emergency department after suffering cardiac arrest at her home. The patient was intubated and ACLS protocol was followed. The patient regained spontaneous circulation after 50 minutes. She was extremely hypotensive so a Norepinephrine infusion was started. Her hand distal to the IV became cyanotic which indicated that Norepinephrine extravasated and was causing severe vasoconstriction. We stopped the infusion of Levophed and a central line was placed.We intentionally placed an arterial line distal to the site through the brachial artery. We injected nitroprusside, a direct vasodilator, through the arterial line which is very uncommon in the ICU as medications are usually injected through the vein, not the artery. We did this in order to deliver nitroprusside directly to the forearm and hand to dilate vessels. We injected 25mg of nitroprusside and the hand immediately turned red and restored circulation. Discussion: Intracoronary nitroprusside, a vasoactive drug, has been used off-label for coronary vasospasms and is commonly used to treat congestive heart failure. Nitroprusside can effectively dilate small arteries and veins, selectively relax vascular smooth muscle and reduce peripheral vascular resistance, temporarily change hemodynamic variables, reduce blood pressure, relieve the cardiac load, and increase cardiac output.3 In the case of vasopressor extravasation, it is important to dilate the vessels in order to flush out the Norepinephrine. It is extremely difficult to perform randomized trials on vasopressor extravasation treatments due to the rare emergency nature and the non-uniformity in the methods of treatment. Although there is no literature on the use of Nitruprosside as a treatment for vasopressor extravasation, its usage in our patient’s treatment was able to successfully, and safely, salvage her hand.