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Paediatric Intensive Care Unit Pharmacopoeia Sodium Nitroprusside Presentation: Indications: Dose: Route of administration: Directions for Administration: Sterile powder for reconstitution for Infusion, 50mg vials. • Afterload reduction • Hypertensive crisis. 0.5 microgram/kg/minute, increasing as needed in steps of 0.2 microgram/kg/minute to maximum 8 microgram/kg/minute (max 4 microgram/kg/minute if used for > 24 hours). Cumulative doses over 3.5mg/kg associated with higher risk of toxicity (see notes below). Intravenous infusion. Maximum concentration for central route (preferred) 1mg in 1mL. Maximum concentration for peripheral administration 200micrograms/mL. Reconstitute each 50mg vial with 2mL of glucose 5% to give 25mg/mL. Central Administration: Patient Amount of Dilute to 50ml 1 mL/hr = Dose Range weight drug to add with either to a 50 mL syringe 3mg x 0.9% saline or 1 ≤15 kg weight (kg) 5% dextrose microgram/kg/minute 0.2 – 8 microgram/kg/minute 1.5mg x 0.9% saline or 0.5 16-30 kg weight (kg) 5% dextrose microgram/kg/minute **Patients >30kg will require a 50mg in 50mL infusion. 1mL/hr will then be equivalent to x micrograms/kg/minute, where x = 16.6 / (patient’s weight in kg). Peripheral Administration: Dilute to a concentration of 200 micrograms/mL. 1mL/hr will then be equivalent to x micrograms/kg/minute, where x = 3.3 / (patient’s weight in kg). Cautions and Contraindications: Common Side Effects: Compatibility (Y – site): Additional Comments: Protect from light by wrapping syringe and giving sets in aluminium foil. Use with caution in renal impairment (avoid prolonged use if GFR < 20 mL/kg/1.73m2), hyponatraemia, hypothermia, hypothyroidism, impaired cerebral circulation. Contraindicated in severe B12 deficiency, Leber’s optic atrophy, severe hepatic impairment. Avoid in compensatory hypertension (e.g. coarctation, AV shunt) or leftsided obstructive lesions (e.g. aortic stenosis or HOCM). Hypotension (monitor BP closely), tachycardia, metabolic acidosis, irritation of skin at cannula site, CNS symptoms, nausea, retching, perspiration Compatible Incompatible Adrenaline Atracurium Calcium chloride Dobutamine Dopamine Esmolol Furosemide Glyceryl trinitrate Heparin Insulin Labetalol Lidocaine Magnesium sulphate Midazolam Milrinone Morphine Noradrenaline Potassium chloride (up to 40mmol/L) Potassium acid phosphate Vecuronium Acetylcysteine Amiodarone Continuous invasive haemodynamic monitoring required. Avoid over-rapid reduction in blood pressure, especially in hypertensive encephalopathy: can result in water shed cerebral infarction, blindness or death. W hen discontinuing, reduce dose slowly over 15-30 minutes to avoid any rebound effects. If used for > 72 hours, measure thiocyanate levels, which should be < 100 microgram/mL (1.7 mmol/L). Lactic acidosis may be the first sign of cyanide toxicity, which also causes tachycardia, sweating, hyperventilation and arrhythmias. If cyanide toxicity suspected, discontinue (slowly- see above) and give antidote: contact National Poisons Information Service. Freshly prepared solution for infusion has a faint brownish tint: discard if changes to dark brown or blue. The solution is stable for 24 hours. Nursing staff to wear gloves, goggles and apron when handling solution. Version 3, June 2014, Review June 2016. Checked: Andrew Wignell, PICU Pharmacist/Adam Henderson, Paediatric Pharmacist Approved: PICU Consultants. Paediatric Intensive Care Unit Pharmacopoeia References 1. 2. 3. 4. 5. nd Medicines for Children, 2 Edition, 2003. BNF for Children, 2013-2014. th Guy’s and Thomas’ Paediatric Formulary, 9 Edition, 2012. rd University College Hospitals Injectable Medicines Administration Guide, 3 Edition, 2010. Trissel LA (ed), Handbook on Injectable Drugs. [online] London: Pharmaceutical Press accessed via www.medicinescomplete.com (accessed on 14/06/2014). 6. Medusa Injectable Medicines Guide: accessed via http://medusa.wales.nhs.uk/ (accessed on 14/06/2014). Version 3, June 2014, Review June 2016. Checked: Andrew Wignell, PICU Pharmacist/Adam Henderson, Paediatric Pharmacist Approved: PICU Consultants.