CLASSESPeripheral Vasodilators, Plain Show
BOXED WARNINGCyanide toxicity Nitroprusside metabolism produces dose-related cyanide. Nitroprusside infusion rates more than 2 mcg/kg/minute generate cyanide ion faster than the body can normally dispose of it. A
patient's ability to buffer cyanide will be exceeded in less than 1 hour at the maximum dose rate (10 mcg/kg/minute); limit infusions at the maximum rate to as short a duration as possible. Discontinue nitroprusside and consider specific treatment (e.g., sodium nitrite, sodium thiosulfate) if cyanide toxicity develops. Most of the cyanide produced during the metabolism of nitroprusside is eliminated in the form of thiocyanate. Thiocyanate is life-threatening when concentrations reach
approximately 200 mg/L; therefore, routine monitoring of plasma thiocyanate concentrations is recommended in patients with normal renal function when cumulative nitroprusside doses exceed 7 mg/kg/day.[51247] [61817] DESCRIPTIONIntravenous direct-acting vasodilator COMMON BRAND NAMESNIPRIDE RTU, Nitropress HOW SUPPLIEDNIPRIDE RTU/Nitropress/Nitroprusside/Sodium Nitroprusside Intravenous Inj Sol: 0.2mg, 0.5mg, 1mL, 25mg DOSAGE & INDICATIONSFor the treatment of hypertensive emergency or hypertensive urgency. Continuous Intravenous Infusion dosage Adults 0.3 to 0.5 mcg/kg/minute continuous IV infusion, initially. Titrate by 0.5 mcg/kg/minute every 5 minutes until desired effect or blood pressure cannot be further reduced without compromising the perfusion of vital organs. Max: 10 mcg/kg/minute for 10 minutes.[51247] [61817] [65597] [65598] Doses more than 2 mcg/kg/minute are associated with an increased risk of cyanide toxicity.[65609] [65771] Infants, Children, and Adolescents 0.3 to 3
mcg/kg/minute continuous IV infusion, initially. Titrate every 5 minutes until desired effect or blood pressure cannot be further reduced without compromising the perfusion of vital organs. Usual dose: 0.5 to 8 mcg/kg/minute. Max: 10 mcg/kg/minute for 10 minutes.[51247] [52076] [52081] [61817] [62353] [64934] Doses more than 2 mcg/kg/minute for more than 24 hours are associated with an increased risk of cyanide toxicity.[52075] Neonates 0.2 to 0.3
mcg/kg/minute continuous IV infusion, initially. Titrate every 5 to 20 minutes until desired effect or blood pressure cannot be further reduced without compromising the perfusion of vital organs. Max: 10 mcg/kg/minute for 10 minutes.[51247] [52082] [52170] [61817] Doses more than 2 mcg/kg/minute for more than 24 hours are associated with an increased risk of cyanide toxicity.[52075] For controlled hypotension induction during anesthesia. Continuous Intravenous Infusion dosage Adults 0.3 mcg/kg/minute continuous IV infusion, initially. Titrate every 5 minutes until desired effect or blood pressure cannot be further reduced without compromising the perfusion of vital organs. Max: 10 mcg/kg/minute for 10 minutes. Infants, Children, and Adolescents 0.3 mcg/kg/minute continuous IV infusion, initially. Titrate every 5 minutes until desired effect or blood
pressure cannot be further reduced without compromising the perfusion of vital organs. Max: 10 mcg/kg/minute for 10 minutes. Neonates 0.25 to 0.5 mcg/kg/minute continuous IV infusion, initially. Titrate every 5 to 20 minutes until desired effect or blood pressure cannot be further reduced without compromising the perfusion of vital organs. Max: 10 mcg/kg/minute for 10 minutes.[51247] [52082] [61817] For the treatment of acute heart failure. Continuous Intravenous Infusion dosage Adults 0.1 to 0.3 mcg/kg/minute continuous IV infusion, initially. Titrate every 5 minutes until desired effect or blood pressure cannot be further reduced without compromising the perfusion of vital organs.[51247] [61817] [65612] Max: 10 mcg/kg/minute for 10 minutes.[51247] [61817] Doses more than 400 mcg/minute generally do not produce added benefit.[65612]
[65779] Guidelines suggest nitroprusside as an adjuvant to diuretics for relief of dyspnea in patients with acutely decompensated heart failure if symptomatic hypotension is absent.[51038] [57101] [62661] Infants, Children, and Adolescents 0.3 to 0.5 mcg/kg/minute continuous IV infusion, initially. Titrate every 5 minutes until desired effect or blood pressure cannot be further reduced without compromising the perfusion of vital organs. Max: 10
mcg/kg/minute for 10 minutes.[51247] [52082] [52102] [61817] Doses more than 2 mcg/kg/minute for more than 24 hours are associated with an increased risk of cyanide toxicity.[52075] Neonates 0.2 to 0.5 mcg/kg/minute continuous IV infusion, initially. Titrate every 5 to 20 minutes until desired effect or blood pressure cannot be further reduced without compromising the perfusion of vital organs. Max: 10 mcg/kg/minute for 10 minutes.[51247] [52082]
[52102] [52170] [61817] Doses more than 2 mcg/kg/minute for more than 24 hours are associated with an increased risk of cyanide toxicity.[52075] For the treatment of postoperative hypertension†. Continuous Intravenous Infusion dosage Adults 0.5 mcg/kg/minute continuous IV infusion, initially. Titrate by 0.5 to 1.5 mcg/kg/minute every 5 minutes until goal blood pressure is attained. Max: 10
mcg/kg/minute for 10 minutes.[24773] Doses more than 2 mcg/kg/minute are associated with an increased risk of cyanide toxicity.[65609] [65771] Infants, Children, and Adolescents 0.3 to 0.5 mcg/kg/minute continuous IV infusion, initially. Titrate every few minutes until goal blood pressure is attained. Usual dose: 0.5 to 8 mcg/kg/minute. Average dose: 3 to 4 mcg/kg/minute. Max: 10 mcg/kg/minute for 10 minutes.[51247] [52078] [52081] [52106] [64934]
Doses more than 2 mcg/kg/minute for more than 24 hours are associated with an increased risk of cyanide toxicity.[52075] Neonates 0.2 to 0.3 mcg/kg/minute continuous IV infusion, initially. Titrate every few minutes until goal blood pressure is attained. Usual dose: 0.5 to 8 mcg/kg/minute. Average dose: 3 to 4 mcg/kg/minute. Max: 10 mcg/kg/minute for 10 minutes. Doses more than 2 mcg/kg/minute for more than 24 hours are associated with an increased
risk of cyanide toxicity. For the treatment of acute mitral regurgitation†. Continuous Intravenous Infusion dosage Adults 15 mcg/minute continuous IV infusion, initially. Titrate by 10 to 15 mcg/minute every 2 minutes until mean arterial pressure decreases by 10 to 20 mmHg. Max: 100 mcg/minute. Nitroprusside reduces afterload and regurgitation fraction. For acute vasodilator testing in pulmonary hypertension diagnosis†. Continuous Intravenous Infusion dosage Adults Dosage not established. Guidelines recommend against use. For the treatment of low cardiac output after cardiopulmonary resuscitation†, cardiac surgery†, or in patients with cardiogenic shock† and high SVR. Continuous Intravenous Infusion dosage
Infants, Children, and Adolescents 0.3 to 1 mcg/kg/minute continuos IV infusion, initially. Titrate every few minutes until desired effect. Usual dose: 0.5 to 8 mcg/kg/minute. Average dose: 3 to 4 mcg/kg/minute. Max: 10 mcg/kg/minute for 10 minutes.[43713] [51247] [51950] [52173] [60636] [64934] Doses more than 2 mcg/kg/minute for more than 24 hours are associated with an increased risk of cyanide toxicity.[52075] Nitroprusside is recommended as a first-line
vasodilator in patients with epinephrine-resistant septic shock and normal blood pressure.[52079] Neonates 0.2 to 0.3 mcg/kg/minute continuous IV infusion, initially. Titrate every few minutes until desired effect. Usual dose: 0.5 to 8 mcg/kg/minute.[52082] [52106] [52170] Average dose: 3 to 4 mcg/kg/minute. Max: 10 mcg/kg/minute for 10 minutes.[43713] [51247] [51950] [52173] [60636] [64934] Doses more than 2 mcg/kg/minute for more than 24 hours are
associated with an increased risk of cyanide toxicity.[52075] †Indicates off-label use MAXIMUM DOSAGEAdults 10 mcg/kg/minute IV for 10 minutes. Geriatric 10 mcg/kg/minute IV for 10 minutes. Adolescents 10 mcg/kg/minute IV for 10 minutes. Children 10 mcg/kg/minute IV for 10 minutes. Infants 10 mcg/kg/minute IV for 10 minutes. Neonates 10 mcg/kg/minute IV for 10 minutes. DOSING CONSIDERATIONSHepatic Impairment Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed. Use caution when administering nitroprusside to patients with hepatic disease; patients with hepatic dysfunction are more susceptible to cyanide toxicity.[51247] [61817] Renal Impairment eGFR 30 mL/minute/1.73 m2 or more: No dosage adjustment needed. ADMINISTRATIONInjectable Administration Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and
container permit. Nitroprusside is a clear, colorless to red/brown solution; do not use if the solution is blue, green, or bright red. Intravenous Administration Single-dose vials Dilution Ready-to-use vials Continuous IV Infusion STORAGENIPRIDE RTU : CONTRAINDICATIONS / PRECAUTIONSAortic coarctation, arteriovenous shunt Nitroprusside is contraindicated for the treatment of compensatory hypertension, where the primary hemodynamic lesion is aortic coarctation or an arteriovenous shunt. Nitroprusside is also contraindicated for use to produce hypotension during surgery in patients with known inadequate cerebral circulation or moribund state (ASA Class 5E) coming to
emergency surgery.[51247] [61817] Acute heart failure, high output acute heart failure Nitroprusside is contraindicated in patients with acute heart failure with reduced peripheral vascular resistance, such as high output acute heart failure that may be seen in endotoxic sepsis.[51247] [61817] Cyanide toxicity Nitroprusside metabolism produces dose-related cyanide. Nitroprusside infusion rates more than 2 mcg/kg/minute generate
cyanide ion faster than the body can normally dispose of it. A patient's ability to buffer cyanide will be exceeded in less than 1 hour at the maximum dose rate (10 mcg/kg/minute); limit infusions at the maximum rate to as short a duration as possible. Discontinue nitroprusside and consider specific treatment (e.g., sodium nitrite, sodium thiosulfate) if cyanide toxicity develops. Most of the cyanide produced during the metabolism of nitroprusside is eliminated in the form of thiocyanate.
Thiocyanate is life-threatening when concentrations reach approximately 200 mg/L; therefore, routine monitoring of plasma thiocyanate concentrations is recommended in patients with normal renal function when cumulative nitroprusside doses exceed 7 mg/kg/day.[51247] [61817] Anuria, renal failure, renal impairment Patients with renal failure may be more susceptible to cyanide toxicity. Use limited, lower mean infusion rates for patients with renal impairment (eGFR
less than 30 mL/minute/1.73m2) or anuria. In renal failure, the nitroprusside half-life can be doubled or tripled.[51247] [52094] [61817] Hepatic disease Use caution when administering nitroprusside to patients with hepatic disease; patients with hepatic dysfunction are more susceptible to cyanide toxicity. Hereditary optic nerve atrophy (Leber's disease), toxic amblyopia Nitroprusside is contraindicated in patients with
hereditary optic nerve atrophy (Leber's disease) or tobacco amblyopia (toxic amblyopia) as such patients have unusually high cyanide/thiocyanate ratios probably associated with defective or absent rhodanase, which is an enzyme that is crucial for the metabolism of nitroprusside.[51247] [61817] Increased intracranial pressure Use nitroprusside with extreme caution in patients with increased intracranial pressure as nitroprusside can cause a further increase in
pressure. Anemia, hypovolemia Correct pre-existing anemia and hypovolemia before using nitroprusside for controlled hypotension during surgery. The patient's ability to compensate for these conditions may be diminished during anesthesia. Hypotensive anesthetic techniques may also cause abnormalities of the pulmonary ventilation/perfusion ratio; patients intolerant of these abnormalities may require a higher fraction of inspired oxygen. Use extreme caution in
patients who are poor surgical risks (ASA Class 4 and 4E).[51247] [61817] Geriatric Use nitroprusside with caution in geriatric patients as they may be more sensitive to the hypotensive effects of nitroprusside.[51247] Pregnancy Prolonged use and large doses of nitroprusside during pregnancy may lead to cyanide toxicity that may be fatal to the fetus. In the unusual case that there is no appropriate alternative to nitroprusside,
advise any pregnant woman of the potential risk to the fetus. Postmarketing reports of nitroprusside use in pregnant women are insufficient to inform a drug-associated risk of adverse pregnancy outcomes. A small number of cases have reported adverse events, including stillbirths, in pregnant women with severe pregnancy-induced hypertension who were treated with nitroprusside. Studies in pregnant sheep demonstrate that nitroprusside crosses the placenta and that fetal cyanide concentrations were
dose-related to maternal concentrations of nitroprusside. The metabolic transformation of nitroprusside administered to pregnant sheep led to fatal concentrations of cyanide in the fetuses.[61817] Breast-feeding Because of the potential for serious adverse reactions in breast-feeding infants, discontinue breast-feeding or discontinue nitroprusside, taking into account the importance of the drug to the mother. There is no information about the presence of
nitroprusside in breast milk, the effects on the breast-fed infant, or the effects on milk production. Thiocyanate, a metabolite of nitroprusside, is present in human milk. It is unknown how long, if ever, concentrations of thiocyanate in milk are clinically relevant.[51247] [61817] ADVERSE REACTIONSSevere methemoglobinemia / Early / 0-1.0 Moderate metabolic acidosis / Delayed / Incidence not known Mild vomiting / Early
/ Incidence not known DRUG INTERACTIONSAcetaminophen;
Chlorpheniramine; Dextromethorphan; Phenylephrine: (Moderate) Use sympathomimetic agents with caution in patients receiving therapy for hypertension. Patients should be monitored to confirm that the desired antihypertensive effect is achieved. Sympathomimetics can increase blood pressure and heart rate, and antagonize the antihypertensive effects of vasodilators when administered concomitantly. Anginal pain may be induced when coronary insufficiency is present.
PREGNANCY AND LACTATIONPregnancy Prolonged use and large doses of nitroprusside during pregnancy may lead to cyanide toxicity that may be fatal to the fetus. In the unusual case that
there is no appropriate alternative to nitroprusside, advise any pregnant woman of the potential risk to the fetus. Postmarketing reports of nitroprusside use in pregnant women are insufficient to inform a drug-associated risk of adverse pregnancy outcomes. A small number of cases have reported adverse events, including stillbirths, in pregnant women with severe pregnancy-induced hypertension who were treated with nitroprusside. Studies in pregnant sheep demonstrate that nitroprusside crosses
the placenta and that fetal cyanide concentrations were dose-related to maternal concentrations of nitroprusside. The metabolic transformation of nitroprusside administered to pregnant sheep led to fatal concentrations of cyanide in the fetuses.[61817] Because of the potential for serious adverse reactions in breast-feeding infants, discontinue breast-feeding or discontinue nitroprusside, taking into account the importance of the drug to the mother. There is no information about the
presence of nitroprusside in breast milk, the effects on the breast-fed infant, or the effects on milk production. Thiocyanate, a metabolite of nitroprusside, is present in human milk. It is unknown how long, if ever, concentrations of thiocyanate in milk are clinically relevant.[51247] [61817] MECHANISM OF ACTIONThe peripheral vasodilatory effects of nitroprusside are due to a direct action of the drug on arterial and venous smooth muscle. Other smooth muscle tissue in the body is not affected, and myocardial contractility is unaffected. Nitroprusside-induced peripheral vasodilation results in a reduced left ventricular afterload, and this, along with a reduced venous return to the heart (due to venous pooling of the blood and decreased arteriolar resistance), results in a slight increase in heart rate and decrease in cardiac output in hypertensive patients. In patients with congestive heart failure, nitroprusside improves left ventricular heart performance, with increases in cardiac index, cardiac output, and stroke volume. Heart rate also slows in these patients, and arrhythmias can be reduced or abolished. Nitroprusside also can decrease myocardial oxygen demand, which is beneficial to patients with ischemia.[51247] [52094] [52097] PHARMACOKINETICSNitroprusside is administered intravenously. It is rapidly distributed to a volume that is approximately coextensive with the extracellular space. The circulatory half-life of nitroprusside is about 2 minutes. Nitroprusside is metabolized by combination with hemoglobin to produce cyanide and cyanmethemoglobin. Methemoglobin, obtained from hemoglobin, can sequester cyanide as cyanmethemoglobin. Nitroprusside metabolism can lead to methemoglobin formation through dissociation of cyanmethemoglobin formed in the original reaction of nitroprusside with hemoglobin and by direct oxidation of hemoglobin by the released nitroso group. Relatively large quantities of nitroprusside are required to produce significant methemoglobinemia. Some cyanide is eliminated from the body as expired hydrogen cyanide, but most is converted to thiocyanate by thiosulfate-cyanide sulfur transferase (rhodanase), a mitochondrial enzyme. This reaction is rate-limited by the availability of sulfur donors (i.e., thiosulfate, cystine, and cysteine). Thiocyanate is eliminated in the urine, with a half-life of about 3 days. A patient with a normal red cell mass and methemoglobin concentrations can buffer approximately 175 mcg/kg of cyanide, which corresponds to a little less than 500 mcg/kg of infused nitroprusside.[51247] [52094] [61817] Affected cytochrome P450 isoenzymes and drug transporters: none Intravenous Route Hypotensive effects occur within 1 to 2 minutes of intravenous administration and persist for 1 to 10 minutes after discontinuing the infusion. What are the most common adverse reactions for nitroprusside?Side Effects. Chest pain or discomfort.. fast, pounding, or irregular heartbeat or pulse.. lightheadedness, dizziness, or fainting.. slow heartbeat.. trouble breathing.. unusual tiredness.. How does sodium nitroprusside decreased blood pressure?Sodium nitroprusside has been used in clinical practice as an arterial and venous vasodilator for 40 years. This prodrug reacts with physiologic sulfhydryl groups to release nitric oxide, causing rapid vasodilation, and acutely lowering blood pressure.
What should the nurse monitor for in a client receiving nitroprusside?Nursing Implications
Monitor heart rate and blood pressure continuously. Monitor renal and hepatic function • Metabolic acidosis is the earliest and most reliable evidence of cyanide toxicity.
Does nitroprusside increase cardiac output?Nitroprusside maintained cardiac output during tamponade despite lowered right atrial pressure but increased cardiac output only after transfusion. less effect upon the venous capacitance bed.
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