NEODOSE

INDICATIONS

• Acute treatment of hypertensive emergencies.
• Acute afterload reduction in patients with refractory congestive heart failure.

FDA APPROVED INDICATION

Indicated for immediate reduction of blood pressure in pediatric patients in hypertensive crises. Indicated for induction and maintenance of controlled hypotension in pediatric patients during surgery, to reduce bleeding.

CONTRAINDICATIONS

• Acute heart failure associated with reduced peripheral vascular resistance.
• Compensatory hypertension (aortic coarctation or arteriovenous shunting).
• Concomitant sildenafil, tadalafil, vardenafil, or riociguat.
• Congenital (Leber) optic atrophy
• Inadequate cerebral circulation or moribund patients (ie, ASA class 5E) coming to emergency surgery.
• Tobacco amblyopia.

PRECAUTIONS

• Anesthesia: Patient’s ability to compensate for anemia and hypovolemia may be diminished; when possible, correct preexisting condition prior to use.
• Hematologic: Methemoglobinemia may occur.
• Hepatic: Hepatic dysfunction predisposes a patient to cyanide toxicity.
• Neurologic: Increases in intracranial pressure can occur.
• Thiocyanate toxicity: Can occur and may be life-threatening when levels reach 200 mg/L; monitoring recommended and dose adjustment may be required, especially in patients with renal impairment or anuria. Renal hemodialysis may be used to eliminate thiocyanate if severe toxicity occurs
• Special Populations: Exercise extreme caution in patients who are especially poor surgical risks(eg, ASA Class 4 and 4E).

ADVERSE EFFECTS

Severe hypotension and tachycardia. Cyanide toxicity may occur with prolonged treatment (greater than 3 days) and high (greater than 3 mcg/kg per minute) doses. Use with caution in liver and renal failure patients due to possible impairment of the metabolism of cyanide to thiocyanate. Extravasation can cause tissue sloughing and necrosis.

ADMINISTRATION

• Administer as a continuous IV infusion at a concentration of 50 to 500 mcg/mL (0.05 to 0.5 mg/mL).
• Use a large vein for IV. Protect infusion from light during administration (not necessary to cover tubing).
• Some institutions use standard concentrations of 60, 125, 200, 400, 500, and 1000 mcg/mL.
• Administer by volumetric infusion pump

BLACK BOX WARNING

• Nitroprusside is not suitable for direct injection; the reconstituted solution must be further diluted in sterile 5% dextrose injection before infusion(the Ready-To-Use solution (200 or 500 mcg/mL) may be used without further dilution).
Nitroprusside can cause precipitous decreases in blood pressure, which may result in irreversible ischemic injuries or death; monitor blood pressure continuously while patient is on therapy.
Except when used briefly or at low (less than 2 mcg/kg/min) infusion rates , sodium nitroprusside gives rise to important quantities of cyanide ion, which can reach toxic, potentially lethal levels. The usual dose rate is 0.5 to 10 mcg/kg/min, but infusion at the maximum dose rate should never last more than 10 minutes. If blood pressure has not been adequately controlled after 10 minutes of infusion at the maximum rate, administration of sodium nitroprusside should be terminated immediately.
• Sodium nitroprusside metabolism produces dose-related cyanide, which can be lethal. A patient’s ability to buffer cyanide will be exceeded in less than one hour at the maximum dose rate (10 mcg/kg/min); limit infusions at the maximum rate to as short a duration as possible.

MONITORING

Continuous heart rate and intra-arterial blood pressure monitoring is mandatory. Daily measurement of RBC cyanide (should be less than 200 ng/mL) and serum thiocyanate (should be less than 50 mcg/mL) concentrations. Assess frequently for development of metabolic acidosis. Daily assessment of renal and hepatic function. Monitor IV site closely.