Change in National Dosing Advice of Nitroprusside After Potentially Fatal Cyanide Intoxication
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MEDICINE
Change in National Dosing Advice of Nitroprusside After Potentially Fatal Cyanide Intoxication Guido Bothof 1 & Koen P. van Rhee 2,3 & Erik Koomen 1 & Esther S. Veldhoen 1 Accepted: 26 March 2020 / Published online: 28 April 2020 # The Author(s) 2020
Abstract The aim of this brief communication is to provide a short overview of cyanide intoxication following infusion of sodium nitroprusside (SNP). SNP is a fast-acting antihypertensive drug frequently used in of hypertensive emergencies. Although SNP is widely known as a safe to use drug, it can cause a potentially lethal cyanide intoxication. The difficulty to diagnose cyanide intoxication and pharmacological principles will be discussed. Hereby, we like to regain attention for this severe complication. As a result of our experience, the Dutch national paediatric drug formulary has been updated with additional warnings and recommendations. Cyanide intoxication due to sodium nitroprusside is a severe and difficult to recognize complication with potentially lethal outcome. Clinicians prescribing sodium nitroprusside should always be aware of its toxic effects. Keywords Nitroprusside . Toxicity . Acidosis . Critical care . Paediatrics . Drug safety
Abbreviations ATP AVSD CN CYANOHGB METHGB NO OXYHGB
Adenosine triphosphate Atrioventricular septal defect Cyanide molecules Cyanomethemoglobin Methemoglobin Nitric oxide Oxyhemoglobin
This article is part of the Topical Collection on Medicine * Guido Bothof [email protected] Koen P. van Rhee [email protected]
PICU SNP
Paediatric intensive care unit Sodium nitroprusside
Introduction Sodium nitroprusside (SNP) is a frequently used antihypertensive drug in intensive care settings after cardiac surgery. Due to its rapid vasodilatory effect, it can be used in case of hypertensive emergency. A known but only rarely reported side effect is cyanide intoxication. Generally, SNP is considered to be a safe drug to use; however, if unaware of its potential danger, it can be lethal [1–3]. In this brief communication, we would like to regain attention to the severe adverse effects of SNP and the difficulty to diagnose cyanide intoxication.
Erik Koomen [email protected]
Clinical Experience
Esther S. Veldhoen [email protected]
A 1-month-old girl was admitted to our paediatric intensive care unit (PICU) after uncomplicated surgical repair of atrioventricular septal defect (AVSD). Within hours after the procedure, the patient was clinically stable and was extubated. Immediately after extubation, she developed severe hypertension with arterial blood pressure levels rising above 140/90 mmHg (p95 for age = 102/ 69 mmHg). Sodium nitroprusside was started at a dose of 0.5 μg/kg/min and was stepwise increased up to 8 μg/kg/min because of insufficient decrease in blood pressure. An ACE
1
Department of Paediatrics, Paediatric Intensive Care Unit, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht, Netherlands
2
Department of Clinical Pharmacology, University Medical Centre Utrecht
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