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Sodium Nitroprusside

Brand names Nitropress, Nipride (Canada)

Medication error ISMP high-alert medication that has an increased risk of causing significant patient harm potential if it is used in error.(1) Look-alike, sound-alike drug names USP reports that nitroprusside has been confused with norepinephrine and and patient harm did not occur. Patient harm resulted when nitroprusside was confused with Neo-Synephrine and nicardipine. Nipride has been confused with nesiritide and patient harm did not occur.(2)

Contraindications U.S. boxed warning: The product must be diluted in D5W prior to infusion.(3) and warnings Precipitous decreases in (BP) can occur. Patients must be continuously monitored with appropriate equipment and by trained personnel during infusion.(3) can reach toxic levels during infusion. Failure to attain the desired response after maximum infusion rate (10 mcg/kg/min) for 10 minutes should result in termina- tion of the infusion.(3) Contraindications: Treatment of compensatory due to aortic coarctation or arteriovenous shunting; patients with known inadequate cerebral circulation or in moribund patients undergoing emergency surgery; patients with Leber congenital optic atrophy or with tobacco amblyopia; or patients with acute coronary with reduced peripheral vascular resistance (e.g., high-output heart failure).(3) Warnings: Excessive and cyanide toxicity are significant risks of nitroprusside administration.(3) (See Adverse Effects in the Comments section.) Use caution in patients with elevated as pressures can elevate further with nitroprusside.(3)

Infusion-related Too rapid decrease in BP can result in serious and permanent neurological sequelae.(3,5,6) cautions Blood pressure should be monitored continuously with an arterial line.(3,6) It has been recommended that the BP be gradually decreased ≤25% in the first 8 hours after pre- sentation followed by gradual normalization of the BP over 26–48 hours.(8) Nitroprusside should only be infused using an infusion pump (e.g., not via gravity).(3)

Dosage Vasodilatation (e.g., for hypertension, deliberate hypotension, or heart failure) Neonates: 0.25–0.5 mcg/kg/min titrated q 20 min. Usual maintenance dose is less than 2 mcg/kg/min; maximum dose for is 10 mcg/kg/min but for no more than 10 minutes, after which infusion rate should be reduced.(9) In 58 neonates with various disease states (respiratory distress syndrome, per- sistent of the newborn, , systemic hypertension, and pulmonary hypoplasia), infusion rates of 0.2–6 mcg/kg/min for 10 minutes to 126 hours were reported.(10) One neonate (28 weeks gestational age) with respiratory distress syndrome received 2 mcg/kg/min for 24 hours, after which the infusion was weaned off over the next 48 hours. The baby required 45 mL/kg blood transfusion to maintain acceptable systolic blood pressure during the infusion.(11) Infants and children: 0.3–1 mcg/kg/min initially titrated by 0.25 mcg/kg/min q 5–10 min until desired response is attained, up to a maximum of 10 mcg/kg/ min.(3,5,7,8,12-21,28) Usual maintenance dose requirement is ≤3 mcg/kg/min in children and adults. The maximum rate of 10 mcg/kg/min should be infused no longer than 10 minutes.(3)

Dosage adjustment Use cautiously in severe hepatic(3) or renal(22) disease due to an increased risk for thiocya- in organ dysfunction nate toxicity.(3) To minimize the risk of toxicity, a prolonged infusion should not exceed 3 mcg/kg/min; in anuric patients, a prolonged infusion should not exceed 1 mcg/kg/min.(3)  788

Maximum dosage 10 mcg/kg/min. Cumulative infusions of 500 mcg/kg at rates faster than 2 mcg/kg/min produce cyanide more rapidly than the body can eliminate it. Coadministration of sodium may reduce cyanide toxicity.(3) In adults, 400 mcg/kg/min was infused for short periods.(23)

Additives Contains 0.335 mEq sodium per 50 mg of sodium nitroprusside.(24,25)

Suitable diluents The manufacturer recommends D5W only(3); however, nitroprusside has also been shown to be stable in LR and NS.(24)

Maximum 200 mcg/mL.(3) 70 mcg/mL was used in children 8–17 years old.(15) In fluid-restricted concentration patients, 1000 mcg/mL has been used.(27)

Preparation and Parenteral products should be visually inspected for particulate matter and discoloration delivery before use. Refer to appropriate references for more information on compatibility with other drugs and solutions, compatibility following Y-site delivery, and suggested storage and extended stability.(24) Preparation: Must be further diluted prior to infusion.(3) (See the Suitable Diluents sec- tion.) Product may be faint brownish in color; however, it should not be used if blue, green, or red, or with visible particulates.(3) Photosensitivity: Protect from light with aluminum foil or other opaque material.(3) Amber plastic coverings may be insufficient protection.(24) It is not necessary to cover the drip chamber or IV tubing.(3)

IV push Not indicated

Intermittent infusion Not indicated

Continuous infusion 50–200 mcg/mL(3)

Other routes of IO(29) administration

Comments Significant adverse effects: Excessive hypotension and cyanide toxicity. Use caution in patients with elevated intracranial pressure as pressures can elevate further with nitro- prusside. Elevated cyanide levels are associated with higher infusion rates, cumulative doses,(3,28,21) and acid-base excess.(21) Cyanide toxicity has been reported after as short a time as 35 minutes.(3) Those with decreased renal function may be at increased risk.(3) Cyanide toxicity results in venous hyperoxemia, lactic acidosis, air hunger, confusion, and death. Acidosis may not occur until more than 1 hour after cyanide concentrations are toxic.(3) In two pediatric studies including 52 and 63 children, the appearance of adverse events was not a reliable predictor of cyanide toxicity.(21,31) One group determined that the mean dose (2 mcg/kg/min for more than 24 hours)(21) was most predictive of increased cyanide concentrations.(20) Treatment of cyanide toxicity: Discontinue sodium nitroprusside and administer sodium and (e.g., commercially available cyanide kit).(3) During nitroprusside infusions (cumulative dose >10 mg/kg), (Hb) can be sequestered as . (>10% of Hb) results in signs of

impaired oxygen delivery despite adequate and arterial PaO2. is an antidote (1–2 mg/kg IV over several minutes) but should be used cautiously.(3)  789