9: Is it safe to peripherally administer norepinephrine?

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Oct 11, 2019

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INSIGHT

Norepinephrine vs Phenylephrine Potency

Ngan Kee's dose-finding study suggests norepinephrine is roughly 10–13 times more potent than phenylephrine by weight in healthy parturients.
Remembering a 10:1 potency ratio is a practical rule of thumb for conversions in most patients.

ADVICE

Use Dilute Peripheral Norepinephrine

Prepare peripheral norepinephrine at dilute concentrations (commonly 4–16 mcg/mL) rather than the higher concentrations used for phenylephrine.
Use institutional standard concentrations and double-check infusion math before administration.

INSIGHT

Large Database Shows Very Few Extravasations

A large retrospective study (≈14,000 pts) found extravasation with peripheral norepinephrine to be extremely rare (~0.035%).
Those few events required no surgical or medical intervention beyond observation.

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We investigate the claim that norepinephrine is not safe for peripheral administration.

Our guests today are Dr. Katarina Ruscic and Dr. Jamie Sparling of the Critical Care Division of the Massachusetts General Hospital.

Full show notes available at depthofanesthesia.com.

Connect with us @DepthAnesthesia on Twitter or depthofanesthesia@gmail.com.

Thanks for listening! Please rate us on iTunes and share with your colleagues.

Music by Stephen Campbell, MD.

References

Cardenas‐Garcia J, Schaub KF, Belchikov YG, Narasimhan M, Koenig SJ, Mayo PH, Peripheral Administration of VM. J. Hosp. Med 2015;9;581-585. doi:10.1002/jhm.2394

Hasanin AM, Amin SA, Agiza NA, Elsayed MK, Refaa S, Hussein HA, Rouk TI, Alrahmany M. Elsayad M. Norepinephrine Infusion for Preventing Postspinal Anesthesia Hypotension during Cesarean Delivery Anesthesiology 2019; 130:55–62.

Medlej K, Kazzi AA, El Hajj Chehade A. Complications from Administration of Vasopressors Through Peripheral Venous Catheters: An Observational Study. The Journal of emergency medicine. 2018; 54(1):47-53.

Ngan Kee, WD A random-allocation graded dose-response study of norepinephrine and phenylephrine for treating hypotension during spinal anesthesia for cesarean delivery. Anesthesiology 2017; 127:934-41

Ngan Kee WD, Lee SWY, Ng FF, Khaw KS. Prophylactic norepinephrine infusion for preventing hypotension during spinal anesthesia for cesarean delivery. Anesth Analg. 2018;126:1989–1994.

Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER) : A Randomized Trial. Am J Respir Crit Care Med. 2019

Parienti JJ, Mongardon N, Mégarbane B. Intravascular Complications of Central Venous Catheterization by Insertion Site. The New England journal of medicine. 2015; 373(13):1220-9.

Ricard J, Salomon L, Boyer A, et al. Central or peripheral catheters for initial venous access of ICU patients. Crit Care Med 2013;41(9):2108-2115.

By listening to this podcast, you agree not to use information as medical advice to treat any medical condition in either yourself or others, including but not limited to patients that you are treating. Opinions expressed are solely those of the host and guests and do not express the views or opinions of Massachusetts General Hospital.