Uses
Hypertensive Crises
For immediate reduction of blood pressure in hypertensive crises (hypertensive emergencies). Administer with other longer-acting hypotensive agents to minimize the duration of nitroprusside therapy.
Can be used for most hypertensive emergencies (e.g., hypertensive encephalopathy, MI, unstable angina pectoris, pulmonary edema, preeclampsia, stroke, head trauma, life-threatening arterial bleeding, aortic dissection).
Caution if high intracranial pressure or azotemia is present.
Acute severe hypertension in preeclampsia (e.g., persistent diastolic blood pressures of ≥105–110 mm Hg): Other antihypertensives (e.g., hydralazine) preferred; sodium nitroprusside reserved for treatment failures.
Ischemic stroke: Clinical trials do not support immediate antihypertensive therapy in these patients.
Contraindicated in compensatory hypertension (e.g., arteriovenous shunt or coarctation of the aorta). (See Contraindications under Cautions.)
Heart Failure and Low-Output Syndromes
Management of acute CHF.
Particularly useful in severe heart failure caused by regurgitant valvular lesions or aortic insufficiency and mitral regurgitation.
Also particularly useful for afterload reduction to unload the left and subsequently right ventricle when left ventricular dysfunction is accompanied by right ventricular ischemia. Monitoring intra-arterial pressure is useful.
Management of low-output syndromes associated with acute MI†; in many cases, other drugs (e.g., nitroglycerin, norepinephrine, dopamine, dobutamine) are preferred.
In acute MI complicated by CHF, nitroglycerin is the preferred vasodilator; nitroprusside can be added when elevated blood pressures are present if nitroglycerin fails to produce optimum blood pressure levels.
Not indicated for the treatment of CHF associated with reduced peripheral vascular resistance. (See Contraindications under Cautions.)
Controlled Hypotension
Used to produce controlled hypotension to reduce bleeding during surgery.
Dosage and Administration
Administration
Administer by IV infusion only.
Administer in a setting with equipment and personnel available to continuously monitor blood pressure.
IV Administration
For solution and drug compatibility information, see Compatibility under Stability.
Administer by IV infusion using a controlled-infusion device to allow precise measurement of flow rate.
When used for the management of acute severe hypertension in preeclampsia, administer before induction of labor.
Reconstitution
Dissolve 50 mg of sodium nitroprusside in 2–3 mL of 5% dextrose injection or sterile water for injection (without preservative). Bacteriostatic water for injection should not be used because preservatives increase the rate of nitroprusside decomposition.
Alternatively, reconstitute ADD-Vantage® vials containing 50 mg according to the manufacturer’s directions.
Dilution
Add the initially reconstituted solution or the commercially available solution containing 50 mg to 250, 500, or 1000 mL of 5% dextrose injection to provide solutions containing 200, 100, or 50 mcg/mL, respectively.
Protect from light by promptly wrapping the container in aluminum foil or other opaque material; it is not necessary to cover the infusion drip chamber or tubing.
Rate of Administration
Adjust rate to maintain the desired hypotensive effect, determined by continuous monitoring of blood pressure, using a continually reinflated sphygmomanometer or, preferably, an intra-arterial pressure sensor.
When sodium nitroprusside is used in CHF, titrate rate based on results of invasive hemodynamic monitoring and urine output.
Dosage
Available as sodium nitroprusside; dosage expressed as sodium nitroprusside.
Pediatric Patients
Hypertensive Crises, Heart Failure and Low-output Syndromes, Controlled Hypotension
IV
Initially, 0.3 mcg/kg per minute; gradually titrated upward every few minutes until adequate blood pressure control is achieved or the maximum infusion rate of 10 mcg/kg per minute is reached. Usual dosage is 3 mcg/kg (range of 0.25–10 mcg/kg) per minute.
Discontinue immediately if adequate reduction in blood pressure is not achieved within 10 minutes in patients receiving the maximum infusion rate of 10 mcg/kg per minute.
Adults
Hypertensive Crises, Heart Failure and Low-output Syndromes, Controlled Hypotension
IV
Initially, 0.3 mcg/kg per minute; gradually titrated upward every few minutes until adequate blood pressure control is achieved or the maximum rate of infusion of 10 mcg/kg per minute is reached. Usual dosage is 3 mcg/kg (range of 0.25–10 mcg/kg) per minute.
Management of a hypertensive emergency: Goal is to reduce mean arterial blood pressure by no more than 25% within minutes to 1 hour, followed by further reduction if stable toward 160/100 to 110 mm Hg within the next 2–6 hours; avoid excessive declines in pressure. If this blood pressure is well tolerated and the patient is clinically stable, further gradual reductions toward normal can be implemented in the next 24–48 hours.
Patients with aortic dissection: Goal is to reduce systolic pressure to <100 mm Hg if tolerated.
Management of acute severe hypertension in preeclampsia: Goal is to reduce diastolic blood pressure to 95–105 mm Hg.
Discontinue immediately if adequate reduction in blood pressure is not achieved within 10 minutes in patients receiving the maximum infusion rate of 10 mcg/kg per minute.
Prescribing Limits
Pediatric Patients
Hypertensive Crises, Heart Failure and Low-output Syndromes, Controlled Hypotension
IV
10 mcg/kg per minute.
Prolonged infusions should not exceed 3 mcg/kg per minute; monitor thiocyanate concentrations if this rate is exceeded for prolonged periods.
Adults
Hypertensive Crises, Heart Failure and Low-output Syndromes, Controlled Hypotension
IV
10 mcg/kg per minute.
Prolonged infusions should not exceed 3 mcg/kg per minute; monitor thiocyanate concentrations if this rate is exceeded for prolonged periods.
Special Populations
Dosage in Renal Impairment
Anuric patients: Prolonged infusions should not exceed 1 mcg/kg per minute (to maintain thiocyanate concentrations <60 mcg/mL).
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