Long-term administration of sodium nitroprusside in childhood

Luderer, John R.; Hayes, Arthur H.; Dubynsky, Orest; Berlin, Cheston M.

doi:10.1016/s0022-3476(77)81332-2

Cited by 29 publications

(7 citation statements)

References 5 publications

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“…Sodium nitroprusside has been used for the treatment of severe hypertension in adults and children with good clinical effect and without hypotensive complications or problems with cyanide toxicity.9 20 The use of incremental infusions, however, requires skilled nursing care and frequent monitoring ofblood pressure. The onset ofaccelerated hypertension is a medical emergency and such labour intensive treatment is justified in order to prevent both further hypertensive and hypotensive complications.…”

Section: Discussionmentioning

confidence: 99%

Management of hypertensive emergencies.

Deal

Barratt

Dillon

1992

Archives of Disease in Childhood

105

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Section: Discussionmentioning

confidence: 99%

Management of hypertensive emergencies.

Deal

Barratt

Dillon

1992

Archives of Disease in Childhood

105

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“…A retrospective study and case reports have been published in which pediatric patients have received nitroprusside infusions for significantly longer periods of time with persistently nontoxic thiocyanate concentrations [7,9] or with thiocyanate concentrations that were in the toxic range but not associated with significant signs or symptoms of toxicity [10].…”

Section: Discussionmentioning

confidence: 99%

Monitoring cyanide and thiocyanate concentrations during infusion of sodium nitroprusside in children

1991

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Over a 19-month period, all requests for blood cyanide and/or serum thiocyanate concentrations to the Clinical Laboratory of The Children's Hospital, Boston, were reviewed in order to determine how physicians screen for nitroprusside-related toxicity. During that period, 52 patients receiving nitroprusside were monitored for cyanide and/or thiocyanate toxicity. Overall, there were 62 cyanide and 86 thiocyanate determinations. None of the thiocyanate determinations and five of the cyanide concentrations were within the toxic range as established by the reference laboratory, and no patient displayed signs or symptoms of toxicity which could not also be explained by their underlying illness. Our findings suggest that while physicians are concerned with nitroprusside toxicity in children, there exists no apparent consensus as to how to monitor for this toxicity. The results also indicate that the relationship between blood cyanide or serum thiocyanate concentrations and clinical evidence of toxicity is not straightforward and requires further delineation.

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“…Indeed, sodium nitroprusside has been recommended in the acute treatment of hypertensive emergencies, or in patients with refractory congestive heart failure [7,8,9,10], with the recommendation of regularly checking blood gas (for the presence of methemoglobinemia and metabolic acidosis), and plasma levels of thiocyanate and lactate. Calcium channel blockers or beta-adrenoreceptor antagonists have been used successfully in the newborn to treat hypertension or various arrhythmias [11], although their use has also been associated with cardiovascular collapse, especially in the newborn [12,13].…”

Section: Sirsmentioning

confidence: 99%

Reply to the letter from C. von Schnakenburg and M. Kr�ger

Cachat

Guignard

2004

Pediatr Nephrol

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Sirs,We thank Drs. von Schnakenburg and Krüger for their comments. They rightfully raise the question of the safety of sodium nitroprusside administration in newborn patients and ask for details of our recently reported patient [1]. The newborn child received sodium nitroprusside for 6 days, at a maximum dosage of 4 mg/kg per min for 48 h, after she failed to respond to several boluses of intravenous hydralazine. The thiocyanate level, measured after 48 h of infusion, was normal at 8 mg/ml (toxic levels >30 mg/ml). Regularly repeated blood analysis never showed lactic acidosis or methemoglobinemia. The child had invasive blood pressure measurement during the entire period of sodium nitroprusside infusion. Blood pressure responded well to that therapy, without any hypotensive episodes.In addition to its potent vasoactive properties, sodium nitroprusside possesses unique toxicities that Dr. von Schnakenburg et al. allude to in their comments. Sodium nitroprusside is rapidly transformed into nitric oxide (NO) and cyanate (CN ). CN is then metabolized/eliminated via three routes: (1) an irreversible transformation into thiocyanate (detoxification), (2) a binding to hydroxycobalamin, to form cyancobalamin (which is eliminated via the kidney), and (3) intracellular metabolism by oxidase, which can lead to cellular asphyxia and lactic acidosis. Methemoglobinemia can also occur [2, 3, 4]. Therefore, sodium nitroprusside administration is not devoid of side effects, although they are deemed to be rare, and often associated with particular pathological conditions (renal failure, malnutrition, hepatic failure, smoking) that can predict their occurrence [2, 3, 5, 6].Our child clearly did not show any side effects of sodium nitroprusside administration.Emergency treatment of hypertension in the neonate remains difficult, with currently very few tested drugs available. Indeed, sodium nitroprusside has been recommended in the acute treatment of hypertensive emergencies, or in patients with refractory congestive heart failure [7,8,9,10], with the recommendation of regularly checking blood gas (for the presence of methemoglobinemia and metabolic acidosis), and plasma levels of thiocyanate and lactate. Calcium channel blockers or beta-adrenoreceptor antagonists have been used successfully in the newborn to treat hypertension or various arrhythmias [11], although their use has also been associated with cardiovascular collapse, especially in the newborn [12,13]. The cardiodepressant adverse effect of calcium channel blockers or beta-adrenoreceptor antagonists is especially pronounced in patients with pre-existing left ventricular impairment [14], as in our patient. We felt that both calcium channel blockers and betaadrenoreceptor antagonists were contraindicated in our patient with severely depressed myocardial function.In summary, in cases of hypertensive emergency with heart failure, sodium nitroprusside is probably a better alternative than continuous administration of calcium channel blockers and beta-adrenoreceptor antagonists,...

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Long-term administration of sodium nitroprusside in childhood

Cited by 29 publications

References 5 publications

Management of hypertensive emergencies.

Management of hypertensive emergencies.

Monitoring cyanide and thiocyanate concentrations during infusion of sodium nitroprusside in children

Reply to the letter from C. von Schnakenburg and M. Kr�ger

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