Adult Dosing

Acute CHF

• Initial: 0.3 mcg/kg/min IV
• Titrate: To desired response
• Usual: 0.3-10 mcg/kg/min. MAX: 10 mcg/kg/min for 10 mins

Hypertensive emergencies

• Initial: 0.3 mcg/kg/min IV
• Titrate: until blood pressure is controlled
• Range: 0.3-10 mcg/kg/min. MAX: 10 mcg/kg/min for 10 min (if adequate blood pressure response is not achieved, discontinue infusion)

• Continuously monitor blood pressure

Pediatric Dosing

Hypertensive emergencies

• Initial: 0.25-0.3 mcg/kg/min IV
• Titrate: until blood pressure is controlled
• Max: 10 mcg/kg/min for 10 min

Note:

• Continuously monitor blood pressure

[Outline]

• Adult Dosing
• Pediatric Dosing

• Immediate Reduction of blood pressure of patients in hypertensive crises
• Producing controlled hypotension in order to reduce bleeding during surgery
• Treatment of acute congestive heart failure

• Hypersensitivity to any of the ingredients of the product
• Treatment of compensatory hypertension
• Aortic coarctation
• Arteriovenous shunting
• During surgery in patients with known inadequate cerebral circulation
• Moribund patients (A.S.A. Class 5E) for emergency surgery
• Congenital (Leber’s) optic atrophy
• Tobacco induced amblyopia
• Acute congestive heart failure associated with reduced peripheral vascular resistance (High-output heart failure)

• Dilute the solution in sterile 5% dextrose injection before infusion
• Decreases blood pressure precipitously, carefully monitor such patients to avoid irreversible ischemic injuries or fatal death
• Use only in facilities where equipment is available to continuously monitor blood pressure
• Cyanide ion can reach toxic, potentially lethal levels except with brief use and with administration at low (< 2 mcg/kg/min) infusion rates
• Usual dose rate is 0.5-10 mcg/kg/min, infusion at the maximum dose rate should never last more than 10 minutes
• Immediately discontinue administration if blood pressure has not been adequately controlled after 10 minutes of infusion at the maximum rate
• Monitor acid-base balance and venous oxygen concentration for indication for cyanide toxicity, these laboratory tests may provide imperfect guidance
• Review package insert thoroughly before administration

Renal Dose Adjustment (Based on CrCl)

• <10 mL/min: Avoid use

Hepatic Dose Adjustment

• Hepatic impairment: Caution advised; dose adjustments not defined

• Excessive low levels hypotension have occurred on transient increase in the infusion rate
• Cyanide ion can reach toxic, potentially lethal levels except with brief use and with administration at low (< 2 mcg/kg/min) infusion rates (US Black box warning)
• Toxic effects of cyanide are rapid, serious, and even lethal
• Put a patient into a head-down (Trendelenburg) position to maximize venous return on occurrence of hypotension
• After discontinuation of infusion, if hypotension persists for few minutes the true cause for hypotension sought out
• Prolonged infusions in patients have led to cyanide toxicity, death has occurred in patients receiving nitroprusside infusions at rates (30-120 mcg/kg/min)
• Elevated cyanide levels, metabolic acidosis, and marked clinical deterioration have occurred in patients receiving infusions at recommended rates for only a few hrs and also for only 35 minutes
• Infusion sodium thiosulfate to overcome cyanide toxicity
• Venous hyperoxemia, metabolic (lactic) acidosis, air hunger, confusion, and fatal death are manifested by cyanide toxicity
• Avoid concomitant use in hypertensive patients, patients receiving other antihypertensive medications
• Capacity to compensate for anemia and hypovolemia have diminished when used for controlling hypotension during anesthesia, correct pre-existing anemia and hypovolemia prior to administration of drug
• Abnormalities of the pulmonary ventilation/perfusion ratio have occurred with hypotensive anesthetic techniques, provide higher fraction of inspired oxygen in such patients
• Signs of cyanide toxicity are not present until an hour or more after the cyanide capacity of the body’s red-cell mass has been exhausted
• Monitor serum thiocyanate levels, acid-base balance, ABGs, blood pressure continuously and Cr at baseline

Cautions: Use cautiously in

• Renal impairment
• Hepatic impairment
• Hypotension
• Cardiovascular disease
• Angina pectoris
• Myocardial infarction
• Ischemic damage
• Cerebrovascular disease
• Ataxia
• Seizures
• Stroke
• Increased intracranial pressure
• Patients with poor surgical risks (A.S.A. Class 4 and 4E)
• Pulmonary disease
• Hypothyroidism
• Anemia
• Hypovolemia
• Hyponatremia
• Vitamin B-12 deficiency
• Poor surgical risk
• Geriatrics

Pregnancy Category:C

Breastfeeding: Safety unknown. Manufacturer advises caution, decision to use the drug to be taken depending on use of the drug to the mother.

• CV: Dyspnea, hypotension, palpitations, reflex tachycardia, bradycardia
• HEMA: Methemoglobinemia, decreased platelet aggregation
• CNS: Dizziness, restlessness, headache, hyperreflexia, apprehension
• NEURO: ICP increased, hyperreflexia
• DERM: Diaphoresis, flushing, rash
• MUSC: Muscle twitching
• GU: Elevated Cr
• LOCAL: Phlebitis
• METABOLIC: Acidosis
• GI: Abdominal pain, nausea, vomiting, ileus, retching, retrosternal discomfort
• ENDO: Hypothyroidism
• EENT: Tinnitus, miosis
• MISC: Thiocyanate toxicity

• Vasodilator; relaxes vascular smooth muscle and consequently dilates peripheral arteries and veins
• Metabolized by RBC's and body tissues to cyanide which is subsequently metabolized by liver to thiocynate
• Renally excreted
• Half-life: 2 mins

US Trade Name(s)

• Nitropress

US Availability

sodium nitroprusside (generic)[Discontinued]

• PWDR for INJ: 25 mg/mL

Nitropress

• PWDR for INJ: 25 mg/mL

Canadian Trade Name(s)

• Nipride

Canadian Availability

Nipride

• PWDR for INJ: 50 mg/vial

UK Trade Name(s)

• N/A

UK Availability

• N/A

Australian Trade Name(s)

• Only generic available

Australian Availability

sodium nitroprusside (generic)

• PWDR for INJ: 50 mg/vial

[Outline]

Cardiovascular

Hypertensive Emergency Agents