[andolini]

In the ISC a new grad. had a patient with hypertension,chronic renal failure, atrial flutter @ 3 to 1 rate of 50. The B/P before nipride drip was 220/110 Dr. ordered nipride drip. The new grad started the drip @ 8mcg. over 24 hours. After 48 hours the drip was finally at 2mcg. The patient developed in the meantime ataxia,confusion and decrease movement to his left lower extremity. He was also on heparin drip. His foley drainage bag had blood in the urine. I over heard the family complaining about the jerking movement that this male did not have prior to nipride infusion as well as complaining about the bld in the urine, the new nurse argued with them his jerking is because he is cold, and the blood in the urine is normal . Then this guy becomes unresponsive MRI an Ct. scan shows no bleed or ischemia. I hear the dr. saying to the family next that this is all normal, I know this doctor pretty long time now and I say to him alone of course that I think this guy is getting too much nipride and having a reaction to cyanide toxicity, he looks at me and said Oh no he will be ok.
Does anyone agree with me?

[jadednurse]

Did you guys draw labs?

[andolini]

do you mean nipride level. no we did not. after 8 days they did creatinine clearance which was high. they asked the docs and the docs stated dont need to.

[jadednurse]

OK, it's been awhile, but when I woked in critical care whenever we had someone on nipride for an extended period of time (forgive me, I can't remember the details of the policy) we regularly drew labs to check for cyanide toxicity.

So, this pt was on nipride for 8 days and no one checked for cyanide toxicity?

[zambezi]

We don't normally draw labs to check for cyanide tox. We do try to keep patient on lower doses of nipride and use other things to supplement. I would be concerned about cyanide tox, esp on 8 mcg (which is ton of cc, at least the way we mix it). As for the blood in urine, was the nurse checking ptts? Sometimes with heparin gtts, the urine is bloody but ptts ok, so we just monitor. If ptt high we adjust accoriding to our protocol. Certainly with the other symptoms, I would have tried another drug just to be sure...

[XIGRIS]

Nipride started at 8mcg/kg/min is very high. It is recommended to start this infusing at 0.5mcg/kg/min and titrate to a desired BP. Anything higher than a 2.5 to 3.0 mcg/kg/min for 2-3 days should be monitored for cyanide toxicity. Nipride toxicity rarely happens however, renal patients and liver patients are more susceptible.

A cyanide kit is always available at the pharmacy. ask for one. if you suspect a toxic level, recommened the kit. then let the patient sniff it.

Also, if the patient is not responsive to this agent, change this dilator to something else.

[Surgical Hrt RN]

Whenever a patient is experiencing neuro changes while on Nipride suspect toxicity!!!!! We just had a patient that this happened to. She was on Nipride for several days and became almost incoherent!!!!! She was not talking, would not respond, and had an overall glazed over look about her. CT scans came back negative, EEG negative, so they finally sent a Cyanide level!!!!! Bingo that was the problem. The patient is now up walking, and feeding herself once again. Some patients have no problem with Nipride, others are more suspectible. Just like anything else I guess!

[Gldngrl]

Where I work, Nipride is a standard drug post op, we start at 0.2mcg/kg/min and on our unit, max is 5mcg/kg/min (10mcg/kg/min in the ICU). Have only drawn a thiocyanate level once. We also use other meds to assist in BP control so we can wean the Nipride off timely. MMB