NIPRIDE RTU IN SODIUM CHLORIDE 0.9%
Clinical safety rating: safe
No significant drug interactions Can cause hypernatremia and fluid overload.
Sodium nitroprusside is a potent vasodilator that acts by releasing nitric oxide (NO), which activates guanylyl cyclase in vascular smooth muscle cells, increasing cGMP levels and leading to relaxation of both arterial and venous smooth muscle, thereby reducing peripheral resistance and cardiac preload.
| Metabolism | Sodium nitroprusside is rapidly metabolized by non-enzymatic reaction with sulfhydryl groups in erythrocytes and tissues to release cyanide. Cyanide is further metabolized to thiocyanate by the mitochondrial enzyme rhodanese in the liver and kidneys. Thiocyanate is renally eliminated. |
| Excretion | Renal: 40-60% as thiocyanate at therapeutic doses; biliary: minimal; fecal: negligible. |
| Half-life | Nitroprusside: ~2 minutes (converted to cyanide); cyanide: 1-2 hours (converted to thiocyanate); thiocyanate: 2.7-7 days (up to 14 days in renal impairment). Clinical context: Thiocyanate accumulation risk with prolonged use. |
| Protein binding | Nitroprusside: negligible; cyanide: 60% (to albumin and other proteins); thiocyanate: 20-40% (primarily albumin). |
| Volume of Distribution | Nitroprusside: 0.2 L/kg; cyanide: 0.3-0.5 L/kg; thiocyanate: 0.2-0.3 L/kg. Clinical meaning: Small Vd indicates limited tissue distribution. |
| Bioavailability | IV: 100% (only route); oral: 0% (not absorbed due to instability and first-pass metabolism). |
| Onset of Action | IV: 30-60 seconds; immediate hypotensive effect. |
| Duration of Action | IV: 1-10 minutes after stopping infusion; rapid offset due to short half-life. |
Initial 0.3-0.5 mcg/kg/min IV continuous infusion, titrate by 0.5 mcg/kg/min every 3-5 minutes to desired effect; usual range 3-6 mcg/kg/min; maximum 10 mcg/kg/min.
| Dosage form | SOLUTION |
| Renal impairment | Contraindicated in severe renal failure (eGFR <30 mL/min) due to risk of thiocyanate toxicity. For eGFR 30-60 mL/min, reduce dose by 50% and monitor thiocyanate levels. No adjustment for eGFR >60 mL/min. |
| Liver impairment | Contraindicated in severe hepatic impairment (Child-Pugh class C). For Child-Pugh class A or B, use with caution; reduce infusion rate by 50% and monitor cyanide levels due to impaired metabolism. |
| Pediatric use | Children: Initial 0.3-0.5 mcg/kg/min IV infusion; titrate by 0.5-1 mcg/kg/min every 5 minutes to effect; usual dose 1-4 mcg/kg/min; maximum 10 mcg/kg/min. Neonates: Not recommended due to limited data and risk of cyanide toxicity. |
| Geriatric use | Elderly: Start at lower end of dosing range (0.25-0.3 mcg/kg/min) due to increased sensitivity and potential renal impairment. Titrate cautiously. Monitor for hypotension and thiocyanate accumulation. |
| 1st trimester | Consult provider |
| 2nd trimester | Consult provider |
| 3rd trimester | Consult provider |
Clinical note
No significant drug interactions Can cause hypernatremia and fluid overload.
| FDA category | Animal |
| Breastfeeding | It is not known if sodium nitroprusside is excreted in human milk. Due to potential for serious adverse reactions in nursing infants (cyanide toxicity), discontinuation of breastfeeding is recommended during therapy and for a period after infusion. M/P ratio not established. |
| Teratogenic Risk | Sodium nitroprusside is a pregnancy category C drug. Animal studies have shown embryotoxicity and teratogenicity (skeletal anomalies) at doses exceeding human therapeutic levels. Fetal risks include cyanide toxicity, hypotension, and metabolic acidosis from maternal infusion, especially in third trimester. Use only if benefit outweighs risk, with caution to avoid maternal hypotension. |
■ FDA Black Box Warning
Sodium nitroprusside can cause excessive hypotension, leading to irreversible cerebral ischemia, myocardial infarction, or death. Also, it can cause cyanide toxicity, especially with prolonged infusion, high doses, or in patients with hepatic impairment. Continuous monitoring of blood pressure and cyanide levels is required.
| Common Effects | fluid replacement |
| Serious Effects |
["Hypersensitivity to sodium nitroprusside","Compensatory hypertension (e.g., coarctation of the aorta, arteriovenous shunting)","Severe hepatic impairment (risk of cyanide toxicity)","Renal failure (risk of thiocyanate toxicity)","Leber's hereditary optic atrophy (risk of cyanide toxicity)","Tobacco amblyopia (risk of cyanide toxicity)"]
| Precautions | ["Monitor blood pressure closely to avoid severe hypotension","Assess for cyanide toxicity, especially in patients with hepatic or renal impairment","Monitor for thiocyanate toxicity, particularly with renal impairment","Use with caution in patients with hypovolemia, severe anemia, or increased intracranial pressure","Avoid prolonged use (beyond 72 hours) due to risk of cyanide accumulation"] |
Loading safety data…
| Fetal Monitoring | Continuous arterial blood pressure monitoring via intra-arterial catheter; heart rate; IV site observation; serum cyanide and thiocyanate levels (if infusion >2 mcg/kg/min or duration >24 hours); acid-base status (metabolic acidosis may indicate cyanide toxicity); fetal heart rate monitoring if maternal hypotension occurs. |
| Fertility Effects | No data available on effects of sodium nitroprusside on human fertility. Animal studies have not been conducted specifically for fertility endpoints. |