Noradrenaline extravasation — FFICM MCQ

Correct answer: E — Leave cannula in place initially and infiltrate local antidote according to protocol

Explanation lettering: C = shown as A · D = shown as C · E = shown as D · A = shown as E

A is correct because the cannula should be left in place initially to aspirate residual drug and infiltrate a local vasodilator antidote such as phentolamine subcutaneously around the leading edge of the extravasation, in line with UK critical care extravasation protocols for peripheral noradrenaline. The presentation of a painful, pale, cool site with local swelling after 25 minutes of peripheral noradrenaline is classic for extravasation-induced local vasoconstriction, and prompt phentolamine (an alpha blocker) reverses this ischaemia by directly antagonising the alpha-1 mediated vasospasm. Removing the cannula before antidote administration removes the direct route for treating the affected tissue and risks progression to necrosis. Immediate stopping of the infusion then protocol-directed local phentolamine treatment via the cannula, is the standard described in UK peripheral noradrenaline extravasation guidance. Why the other options are wrong: B. Remove and apply tight compression bandage: compression further reduces perfusion to already ischaemic tissue and will worsen, not treat, the vasoconstrictive injury; the cannula should not be removed before antidote infiltration. C. Inject calcium gluconate into the site: calcium gluconate is the antidote for extravasation of calcium channel blockers or for hyperkalaemia/hypocalcaemia, not for alpha-agonist vasopressor extravasation; it has no role in reversing noradrenaline-induced vasoconstriction. D. Ignore the injury because the dose was low: pale, cool, painful skin with swelling indicates established local ischaemia regardless of the dose infused, and untreated it can progress to skin necrosis requiring plastic surgical intervention. E. Apply ice packs for prolonged vasoconstriction: cold packs cause further vasoconstriction and will exacerbate the ischaemic injury; warmth, not cold, is used to promote local vasodilation. Key point: extravasation of peripheral noradrenaline causing local ischaemia is treated by leaving the cannula in situ to aspirate and infiltrate phentolamine (alpha blocker antidote) before removal, never by compression or cooling.

Reference: Royal Cornwall Hospitals NHS Trust, Peripheral Administration of Noradrenaline (pNA) Clinical Guideline V1.0, extravasation management section (phentolamine 10mg in 10mL 0.9% saline, subcutaneous infiltration around leading edge before cannula removal), https://doclibrary-rcht.cornwall.nhs.uk/GET/d10366271