Usual Adult Dose for Congestive Heart Failure

0.3 mcg/kg/min infusion; evaluate blood pressure for at least 5 minutes before titrating to a higher or lower dose to achieve desired blood pressure; upward titration may be implemented until the desired effect is achieved, systemic blood pressure cannot be further reduced without compromising vital organ perfusion, or the maximum recommended infusion rate has been reached, whichever occurs first.

Maximum dose: 10 mcg/kg/min

Comments:

• This drug must be delivered by a volumetric infusion pump.
• Monitor blood pressure continuously.
• When used in the treatment of acute heart failure, titration must be guided by invasive hemodynamic monitoring with simultaneous monitoring of urine output.

Uses:

• Immediate reduction of blood pressure of adult patients in hypertensive crises.
• Induction and maintenance of controlled hypotension during surgery to reduce bleeding.
• Treatment of acute heart failure to reduce left ventricular end diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure.

Usual Adult Dose for Hypertensive Emergency

0.3 mcg/kg/min infusion; evaluate blood pressure for at least 5 minutes before titrating to a higher or lower dose to achieve desired blood pressure; upward titration may be implemented until the desired effect is achieved, systemic blood pressure cannot be further reduced without compromising vital organ perfusion, or the maximum recommended infusion rate has been reached, whichever occurs first.

Maximum dose: 10 mcg/kg/min

Comments:

• This drug must be delivered by a volumetric infusion pump.
• Monitor blood pressure continuously.
• When used in the treatment of acute heart failure, titration must be guided by invasive hemodynamic monitoring with simultaneous monitoring of urine output.

Uses:

• Immediate reduction of blood pressure of adult patients in hypertensive crises.
• Induction and maintenance of controlled hypotension during surgery to reduce bleeding.
• Treatment of acute heart failure to reduce left ventricular end diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure.

Usual Adult Dose for Induced Hypotension

0.3 mcg/kg/min infusion; evaluate blood pressure for at least 5 minutes before titrating to a higher or lower dose to achieve desired blood pressure; upward titration may be implemented until the desired effect is achieved, systemic blood pressure cannot be further reduced without compromising vital organ perfusion, or the maximum recommended infusion rate has been reached, whichever occurs first.

Maximum dose: 10 mcg/kg/min

Comments:

• This drug must be delivered by a volumetric infusion pump.
• Monitor blood pressure continuously.
• When used in the treatment of acute heart failure, titration must be guided by invasive hemodynamic monitoring with simultaneous monitoring of urine output.

Uses:

• Immediate reduction of blood pressure of adult patients in hypertensive crises.
• Induction and maintenance of controlled hypotension during surgery to reduce bleeding.
• Treatment of acute heart failure to reduce left ventricular end diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure.

Usual Adult Dose for Hypertensive Urgency

0.3 mcg/kg/min infusion; evaluate blood pressure for at least 5 minutes before titrating to a higher or lower dose to achieve desired blood pressure; upward titration may be implemented until the desired effect is achieved, systemic blood pressure cannot be further reduced without compromising vital organ perfusion, or the maximum recommended infusion rate has been reached, whichever occurs first.

Maximum dose: 10 mcg/kg/min

Comments:

• This drug must be delivered by a volumetric infusion pump.
• Monitor blood pressure continuously.
• When used in the treatment of acute heart failure, titration must be guided by invasive hemodynamic monitoring with simultaneous monitoring of urine output.

Uses:

• Immediate reduction of blood pressure of adult patients in hypertensive crises.
• Induction and maintenance of controlled hypotension during surgery to reduce bleeding.
• Treatment of acute heart failure to reduce left ventricular end diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure.

Usual Pediatric Dose for Congestive Heart Failure

0.3 mcg/kg/min infusion; evaluate blood pressure for at least 5 minutes before titrating to a higher or lower dose to achieve desired blood pressure; upward titration may be implemented until the desired effect is achieved, systemic blood pressure cannot be further reduced without compromising vital organ perfusion, or the maximum recommended infusion rate has been reached, whichever occurs first.

Maximum dose: 10 mcg/kg/min

Comments:

• This drug must be delivered by a volumetric infusion pump.
• Monitor blood pressure continuously.
• When used in the treatment of acute heart failure, titration must be guided by invasive hemodynamic monitoring with simultaneous monitoring of urine output.

Uses:

• Immediate reduction of blood pressure of pediatric patients in hypertensive crises.
• Induction and maintenance of controlled hypotension in children during surgery to reduce bleeding.
• Treatment of pediatric patients with acute heart failure to reduce left ventricular end diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure.

Usual Pediatric Dose for Hypertensive Emergency

0.3 mcg/kg/min infusion; evaluate blood pressure for at least 5 minutes before titrating to a higher or lower dose to achieve desired blood pressure; upward titration may be implemented until the desired effect is achieved, systemic blood pressure cannot be further reduced without compromising vital organ perfusion, or the maximum recommended infusion rate has been reached, whichever occurs first.

Maximum dose: 10 mcg/kg/min

Comments:

• This drug must be delivered by a volumetric infusion pump.
• Monitor blood pressure continuously.
• When used in the treatment of acute heart failure, titration must be guided by invasive hemodynamic monitoring with simultaneous monitoring of urine output.

Uses:

• Immediate reduction of blood pressure of pediatric patients in hypertensive crises.
• Induction and maintenance of controlled hypotension in children during surgery to reduce bleeding.
• Treatment of pediatric patients with acute heart failure to reduce left ventricular end diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure.

Usual Pediatric Dose for Induced Hypotension

0.3 mcg/kg/min infusion; evaluate blood pressure for at least 5 minutes before titrating to a higher or lower dose to achieve desired blood pressure; upward titration may be implemented until the desired effect is achieved, systemic blood pressure cannot be further reduced without compromising vital organ perfusion, or the maximum recommended infusion rate has been reached, whichever occurs first.

Maximum dose: 10 mcg/kg/min

Comments:

• This drug must be delivered by a volumetric infusion pump.
• Monitor blood pressure continuously.
• When used in the treatment of acute heart failure, titration must be guided by invasive hemodynamic monitoring with simultaneous monitoring of urine output.

Uses:

• Immediate reduction of blood pressure of pediatric patients in hypertensive crises.
• Induction and maintenance of controlled hypotension in children during surgery to reduce bleeding.
• Treatment of pediatric patients with acute heart failure to reduce left ventricular end diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure.

Usual Pediatric Dose for Hypertensive Urgency

0.3 mcg/kg/min infusion; evaluate blood pressure for at least 5 minutes before titrating to a higher or lower dose to achieve desired blood pressure; upward titration may be implemented until the desired effect is achieved, systemic blood pressure cannot be further reduced without compromising vital organ perfusion, or the maximum recommended infusion rate has been reached, whichever occurs first.

Maximum dose: 10 mcg/kg/min

Comments:

• This drug must be delivered by a volumetric infusion pump.
• Monitor blood pressure continuously.
• When used in the treatment of acute heart failure, titration must be guided by invasive hemodynamic monitoring with simultaneous monitoring of urine output.

Uses:

• Immediate reduction of blood pressure of pediatric patients in hypertensive crises.
• Induction and maintenance of controlled hypotension in children during surgery to reduce bleeding.
• Treatment of pediatric patients with acute heart failure to reduce left ventricular end diastolic pressure, pulmonary capillary wedge pressure, peripheral vascular resistance, and mean arterial blood pressure.

Renal Dose Adjustments

eGFR 30 mL/min/1.73 m2 or greater: Data not available
eGFR less than 30 mL/min/1.73 m2: Limit mean infusion rate to less than 3 mcg/kg/min
Anuric patients: Limit mean infusion rate to 1 mcg/kg/min

Liver Dose Adjustments

Use with caution.

Precautions

US BOXED WARNINGS:

• ADMINISTRATION: Nitropress(R) is not suitable for direct injection. The solution must be further diluted in sterile 5% dextrose injection before infusion.
• EXCESSIVE HYPOTENSION: This drug can cause precipitous decreases in blood pressure which can lead to irreversible ischemic injuries or death. Use only with continuous blood pressure monitoring.
• CYANIDE TOXICITY: Metabolism of this drug 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). Infusions at the maximum 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 this drug should be terminated immediately. Although acid-base balance and venous oxygen concentration should be monitored and may indicate cyanide toxicity, these laboratory tests provide imperfect guidance.

CONTRAINDICATIONS:

• Diseases with compensatory hypertension (e.g., coarctation of the aorta, arteriovenous shunting)
• Patients with inadequate cerebral circulation or in moribund patients (American Society of Anesthesiologists [ASA] Class 5E) coming to emergency surgery
• Congenital (Leber's) optic atrophy or tobacco amblyopia
• Acute heart failure associated with reduced peripheral vascular resistance
• Concomitant use of sildenafil, tadalafil, vardenafil, or riociguat

Consult WARNINGS section for additional precautions.

Dialysis

Data not available

Other Comments

Administration advice:

• This drug must be delivered by a volumetric infusion pump.
• Do not use flexible container in series connections.

Storage requirements: The manufacturer product information should be consulted.

Reconstitution/preparation techniques: The manufacturer product information should be consulted.

IV compatibility: Do not administer other drugs in the same solution with this drug.

Monitoring:

• Cardiovascular: Blood pressure (continuously)
• Genitourinary: Urine output (for acute heart failure)
• Hematologic: Invasive hemodynamic monitoring (for acute heart failure)
• Metabolic: Plasma thiocyanate levels (in patients with normal renal function when cumulative doses of this drug exceed 7 mg/kg/day); Acid-base balance; Venous oxygen concentration

Patient advice: Inform female patients of reproductive potential that this drug may cause fetal harm and to inform their prescriber of a known or suspected pregnancy.