Are (mostly) safe! Norepinephrine, epinephrine, and phenylephrine have great safety profiles when used peripherally. Vasopressin should never be used peripherally due to its ability to cause peripheral ischemia with no antidote. Unlike vasopressin, the other pressors do have antidotes if they extravasate.  

Some strategies for reducing extravasation of peripheral pressors  

Use a longer catheter 

Use ultrasonographic guidance for placing the pressor IV  

Use the biggest, most superficial vein there is  

Use the most dilute concentration of pressor available  

Run the pressor for the shortest amount of time peripherally as possible  

Know which line is running the pressor and observe it  

If the peripheral pressor extravasates:  

Stop the infusion and switch to a different line  

Leave the infiltrated catheter in place  

Draw back on infiltrated catheter and remove as much infiltrate as possible  

Elevate extremity with warm compresses  

Antidotes (but NOT for vasopressin) 

Phentolamine: α antagonist -> vasodilation. Inject into surrounding skin and through catheter. Repeat dosing not well-established.  

Terbutaline: β2 agonist -> vasodilation. Inject into surrounding skin and through catheter. Can repeat dose q15min.  

Nitro paste: release of NO -> vasodilation. Can apply paste to surrounding area q8hrs.  

Farkas, Josh. The Internet Book of Critical Care. Vasopressors. Accessed on December 7th, 2021. Available at https://emcrit.org/ibcc/pressors/.  

Farkas, Josh. The Internet Book of Critical Care Podcast 78 – Vasoactive Agents. Published on February 20th, 2020. Accessed on December 7th, 2021. Available athttps://emcrit.org/pulmcrit/pressors/.  

Kim SM, Aikat S, Bailey A. Well recognised but still overlooked: norepinephrine extravasation. BMJ Case Reports 2012;2012:bcr2012006836:. doi: 10.1136/bcr-2012-006836. 

Khanna, A et al. Angiotensin II for the treatment of vasodilatory shock. NEJM 2017;377:419-430. doi: 10.1056/NEJMoa1704154. 

Manaker, Scott. Use of vasopressors and inotropes. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. (Accessed December 7th, 2021)  

Parekh M, Andreae M. EM Resident. The Crashing Patient with Critical Aortic Stenosis. Published October 3rd, 2017. Accessed on December 9th, 2021. Available at https://www.emra.org/emresident/article/the-crashing-patient-with-critical-aortic-stenosis/. 

Rezaie, Salim. Rebel EM. Peripheral Pressors: 6 Pearls Not to F*#k Up the Arm. Published on June 4th, 2020. Accessed on December 7th, 2021. Available at https://rebelem.com/peripheral-pressors-6-pearls-to-not-fk-up-the-arm/.  

Shields SH, Holland RM. Pharmacology of vasopressors and inotropes. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th edition. New York, NY: McGraw-Hill Education; 2020: 133-137.