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nitroprusside

Brand: Nipride

⚠ BBW ISMP High Alert Prototype Drug
Drug Class: direct vasodilator
Drug Family: antihypertensive
Subclass: nitric oxide donor
Organ Systems: cardiovascular

Mechanism of Action

Releases nitric oxide directly causing activation of guanylyl cyclase and increased cGMP; relaxes both arterial and venous smooth muscle reducing preload and afterload; most potent IV antihypertensive.

guanylyl cyclase (via NO)

Indications

  • hypertensive emergency (rapid titration)
  • acute aortic dissection (after beta-blocker)
  • acute HF with severe afterload increase
  • controlled hypotension during surgery

Contraindications

  • compensatory hypertension (AV shunt, coarctation)
  • high intracranial pressure (increases ICP)
  • Leber hereditary optic neuropathy
  • tobacco-amblyopia

Adverse Effects

Common

  • hypotension
  • reflex tachycardia
  • nausea

Serious

  • cyanide toxicity (hepatic accumulation)
  • thiocyanate toxicity (renal accumulation)
  • severe hypotension

Pharmacokinetics (ADME)

Absorption IV only
Distribution rapid tissue distribution
Metabolism spontaneous release of NO + cyanide
Excretion hepatic (cyanide → thiocyanate); renal (thiocyanate)
Half-life minutes
Onset immediate
Peak immediate
Duration seconds-minutes
Protein Binding <0%
Vd low

Drug Interactions

Drug / Agent Mechanism Severity
other antihypertensives additive severe hypotension major

Nursing Considerations

  1. Protect from light during administration (photodegrades to cyanide)
  2. Monitor for cyanide toxicity: metabolic acidosis, altered consciousness, tachyphylaxis — treat with hydroxocobalamin or sodium thiosulfate
  3. Maximum dose: 10 mcg/kg/min; maximum infusion duration 72 hours
  4. Titrate every 3-5 minutes to target BP
  5. Monitor thiocyanate levels in renal impairment

Clinical Pearls

  • Cyanide toxicity: metabolic acidosis + elevated mixed venous PO2 (cells can't utilize O2) + tachyphylaxis
  • Hydroxocobalamin (Cyanokit) is antidote for cyanide toxicity
  • Light-sensitive: must wrap infusion bag and tubing in opaque cover

Safety Profile

Pregnancy avoid
Lactation avoid
Renal Adjustment Required
Hepatic Adjustment Required
TDM Not required

Concordance Terms

Cross-referenced clinical concepts — click any term to see all content where it appears.

Acute Aortic Dissection (after Beta-blocker) Acute HF With Severe Afterload Increase Controlled Hypotension During Surgery Direct Vasodilator Hypertensive Emergency (rapid Titration)
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