Amazed with Nipride

Nipride (SNP) is a powerful drug and some people respond dramatically to it. When I start a gtt, I usually start at a low dose of about .20-.40 mcg/kg/min or just a few ml/min. (Are you sure your book said 1.0 or did it say 0.1? Just curious.)

We frequently use SNP with Epi to help improve a CI. SNP can be a very dangerous drug however at higher doses. If you ever notice that your patient is not oxygenating well and your SNP is running near 2mcg/kg/min, consider cyanide toxicity. Because cyanide is a product of the breakdown of SNP by the body, cyanide toxicity even at low doses and especially if your patient has any type of renal impairment can easily occur.

This has happened to me twice in the last couple of years! You can start seeing symptoms as quickly as 10 minutes after starting the drip. I also read somewhere that at doses of about 3mcg/kg/min, pulmonary shunting can occur again causing respiratory problems. My experience has also been that people on higher doses tend toward being restless or agitated if not sedated well even when I'm not running epi.

SNP's good cause it has a very short half-life (1-10 min) so when your patient does drop their pressure all you really need to do is titrate your gtt down or pause it momentarily and then restart it at a lower rate.

It takes a while to learn everything about the vent. It's a whole seperate beast! But it sounds like you had a great patient for one of your first solitary experiences. Good for you!

:)

Good job with your first solo patient - I have to admit, we seldom give a patient with quite that many things going on to someone new off orientation on our unit. :)

A quick couple of comments on Nipride - we use it very frequently especially as we are a med/surg/neuro ICU and our neuro patients tend to run high when they're at risk for bleeds. Anyway, like Begalli noted, nipride is very potent but has a short half-life, so you can always start slow but also remember that you can just shut it off and start at lower doses. About the cyanide toxicity... do you not have your nipride mixed with sodium thiosulfate? I thought it was a requirement. This is actually the antidote for cyanide toxicity. Our nipride gtts are always mixed with sodium thiosulfate and we run patients on HIGH doses of nipride at times (I have seen 5 mcg/kg/min and up) for long periods of time, and we do not ever have incidences of cyanide toxicity.

I am personally afraid of Nipride. Maybe because the one time I titrated up 1/2 a mic or so, I left the room to grab something and when I got back my patient was diaphoretic and getting ready to lose her lunch because her pressure went from 140 to 60. Good afterload reducer though. Super good in this case.

I keep a little laminated ring with handy information on little credit card sized cards. All the major pressors on them with start drips rates, and weaning parameters most commonly used. I've used it a lot.

Beware with using anything that might flush the line and deliver a little extra nipride to your patient. Just flushing the CVP can show a drop the pressure.

Sounds like you did a great job. I work in CVICU so we use nipride all the time for the immediate post-op period. Nipride is a great drug but can be tricky to find the right amount the pt needs. When we're titrating all the time for it we call it "playing the nipride game"

Anyway... starting low with this drug is always a good idea (which you obviously know now, it is pretty amazing how fast it works) Some pt's respond to just a few drops of it. I had a pt just last night how required a pretty high dose of nipride and as others have said at high doses you can get pulmonary shunting (as well as cyanide toxicity, but our bags have sodium thiosulphate to help prevent this). If shunting occurs you're going to want to get another drug on-board so you can come down on your nipride. Also to be on the safe side you'll probably want to check a methemoglobin level. If that's elevated you can give methylene blue to reverse it and that may fix your problem.

Nipride in my opinion is a drug like any other vasoactive drug you just have to have respect for

I work in CVICU and use nipride frequently. I'd never start a patient at 1mcg. We start at 1 ml, which I couldn't even tell you what that is in mcgs but it's something like 0.234 or some ridiculous number like that. When we titrate, we titrate by the ml, not by the mcgs, because as a poster earlier stated, some folks are very sensitive to it. Last week I recovered a fresh open heart who came to me with an SBP of 190. Started nipride - the highest I ever got it on him was 0.644mcg. That number I remember because it was the last and most frequent number I charted.

You will sometimes see a patient who requires a 1mcg dose or higher, but I'd never start that high and I'd never walk away from the patient or the monitor until I was sure the SBP had stabilized at the current dose. Even then, I'd be pretty darn vigilant.

Sounds like you had quite a challenge on your hands. Kudos for dealing with it and not freaking out!