Ischemic Necrosis Due to Administration of Metaraminol

Abstract

The use of sympathomimetic amines, such as arterenol (Levophed) bitartrate and metaraminol (Aramine) bitartrate, as vasopressor agents in the treatment of clinical hypotension has received widespread acceptance. The occurrence of ischemic necrosis secondary to the administration of arterenol has been well documented.1 Due to the physiological similarity of these drugs it could be expected that such a complication would arise with extensive use of metaraminol. One such case was reported recently.2 The following is a report of a similar case.A 62-year-old man was admitted to the Latter\x=req-\ day Saints Hospital on April 17, 1959, with the type of electrocardiographic changes found in patients with acute, posterior myocardial infarction, a white blood cell count of 11,200 per cubic millimeter, and a serum transaminase level of 56 Todd units. At the time of admission the patient's blood pressure was 130/100 mm. Hg in both arms, and his pulse rate was 60 per minute and regular. On the third hospital day the patient suddenly became unresponsive. Neither respirations, pulse, nor blood pressure could be obtained. Artificial respiration was instituted, after which the patient began Cheyne-Stokes respirations. He was given, intravenously, 2 cc. of methoxamine (Vasoxyl) hydrochloride and 2 cc. of nikethamide (Coramine). An intravenous infusion of 50 mg. of metaraminol diluted with 5% dextrose in 1,000 cc. of water was started in the right antecubital vein. The heart sounds once more were audible, but were noted to be irregular. An electrocardiogram showed varying degrees of atrioventricular block, with a ventricular rate of 60 per minute.The intravenous infusion infiltrated after 16 hours, and a cut-down was done in the right greater saphenous vein. Since, because of vasospasm, a polyethylene catheter could not be inserted, an 18-gauge needle was tied in and left in place. Because of the appearance of bilateral basilar rales the patient was digitalized with 1.2 mg. of intravenously given lanatoside C (Cedilanid) over a 6-hour period. The infusion dose of metaraminol was increased to 100 mg. diluted with 5% dextrose in 1,000 cc. of sterile water and given at a rate of 30 drops per minute. On the fifth hospital day the patient's blood pressure was 90/60 mm. Hg and the pulse rate 44 per minute, with a 2:1 atrioventricular block. There was noted to be an area of discoloration extending proximally from the site of the cutdown. This was about 11 by 8 cm., with a bluish discoloration of the edges and central blanching.There were three bullous, vesicular lesions varying from 1 to 2.5 cm. in diameter. The cut-down was discontinued, restarted in the left leg, and continued until the patient's death. The site was then infiltrated with 5 mg. of phentolamine (Regitine) hydrochloride in 20 cc. of distilled sterile water; however no change was noted. The infiltrated right antecubital fossa remained normal. On the eighth hospital day the patient died. At this time it was noted that the vesicles had ruptured and the underlying tissue was ...

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