Papaverine, an opium alkaloid, is a potent vasodilator and antispasmodic commonly used for the management of vascular spasms or cardiac extrasystole either as an intravenous (IV) bolus or intramuscular injection in adult patients. Although clinical evidence for papaverine use is limited in pediatric populations, a 2008 review of papaverine discussed the pharmacology, dosing, and evidence for use in peripheral arterial lines for neonatal treatment. Papaverine continuous IV infusions have been utilized to manage peripheral arterial catheter (PAC) patency, reducing catheter failure risk and increasing the duration of catheter function; catheter failure is associated with vasospasm events, resulting in an inability to draw blood or drip from PAC. Despite the overall clinical benefit for catheter retention, papaverine use in premature infants within the first few days following birth should be administered with caution as these patients are at a heightened risk for intraventricular hemorrhage. Papaverine infusion is recommended to be administered as an admixture of 30 mg/mL papaverine, 250 mL of standard peripheral line solution (0.9% or 0.45% normal saline), and sodium heparin 1 U/mL. For the prevention of vasospasm, papaverine solution is recommended to be infused at a rate of ≤1 mL/hour. Significantly, evidence for a defined infusion rate was not provided by the study authors. Admixture recommendations are derived from studies conducted by Heulitt et al. and Griffin et al. Please refer to Tables 1 and 2, for further details. [1]
A 2016 study retrospectively analyzed 14 extremely low birth weight (ELBW) neonates who developed skin discoloration subsequent to peripheral arterial catheterization. The primary intervention involved the use of intra-arterial papaverine, specifically at a dose of 1 mg/kg diluted with saline (1 mg:1 mL) and infused over 5-10 minutes before the arterial line removal. Following this, nitroglycerin (NTG) patches were applied to further assist in vasodilation. Skin discoloration, which was indicative of either vasospasm or thromboembolism, was the focal point of assessment. Notably, out of the 14 neonates, 11 received papaverine (gestational age 26-31 weeks; weight 0.56-0.98 kg), and all showed recovery. In 6 cases, normal skin color reappeared within 4 hours, and in the remaining 5, normalization occurred over a few days without residual damage. Three neonates could not receive papaverine due to arterial line blockages. Of these, two achieved spontaneous recovery, while one progressed to gangrene of the fingers. The report highlights the potential utility of papaverine in mitigating ischemic complications associated with peripheral arterial catheterization in ELBW neonates. However, limitations included the study’s retrospective design, the absence of a control group, the use of an additional intervention (NTG patch), and a relatively small sample size. Although these findings suggest the efficacy of papaverine in preventing ischemic injury, they underscore the need for well-controlled studies to substantiate the observed outcomes. It should also be noted that these results were only presented as an abstract and may not be comprehensive. [2]