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Sani M, Sebai H, Refinetti R, Mondal M, Ghanem-Boughanmi N, Boughattas NA, Ben-Attia M. Effects of sodium nitroprusside on mouse erythrocyte catalase activity and malondialdehyde status. Drug Chem Toxicol 2016; 39:350-6. [PMID: 26738972 DOI: 10.3109/01480545.2015.1122032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
There is controversy about the anti- or pro-oxidative effects of the nitric oxide (NO)-donor sodium nitroprusside (SNP). Hence, the activity of the antioxidant enzyme catalase (CAT) and the status of malondialdehyde (MDA) were investigated after a 2.5 mg/kg dose of SNP had been i.p. administered to different and comparable groups of mice (n = 48). The drug was administered at two different circadian times (1 and 13 h after light onset [HALO]). There were, irrespectively of sampling time, no significant differences in the means of CAT activity and MDA status between control and SNP-treated groups, no matter the treatment time. However, CAT activity was significantly (Student's t-test, p < 0.001) increased 1 h following SNP administration at 1 HALO, whereas the significant (p < 0.001) increase in the enzyme activity was found only 3 h after injection at 13 HALO. The drug dosing either at 1 or 13 HALO resulted in no significant differences of MDA status between control and treated groups regardless to the sampling time. Two-way analysis of variance (ANOVA) detected a significant (F0.05(7,88)= 5.3; p < 0.0006) interaction between sampling time and treatment in mice injected at 1 HALO, suggesting the influence of treatment on sampling-time-related changes in CAT activity. However, ANOVA validated no interaction between the two factors in mice treated at 13 HALO, illustrating that the sampling-time differences in enzyme activity were greater. Furthermore, two-way ANOVA revealed no interaction in the variation of MDA status in animals treated either at 1 or 13 HALO. This study indicates that SNP significantly affected the anti-oxidant system.
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Affiliation(s)
- Mamane Sani
- a Département De Biologie, Faculté Des Sciences Et Techniques De Maradi , UMR Biosurveillance Et Toxicologie Environnementale , Maradi , Niger .,c Circadian Rhythm Laboratory , Boise State University , Boise , ID , USA
| | - Hichem Sebai
- b Département Des Sciences De La Vie , UR Ethnobotanie Et Stress Oxydant , Zarzouna , Tunisia
| | - Roberto Refinetti
- c Circadian Rhythm Laboratory , Boise State University , Boise , ID , USA
| | - Mohan Mondal
- d National Dairy Research Institute , Kalyani , West Bengal , India
| | - Néziha Ghanem-Boughanmi
- b Département Des Sciences De La Vie , UR Ethnobotanie Et Stress Oxydant , Zarzouna , Tunisia
| | - Naceur A Boughattas
- e Laboratoire De Pharmacologie, Faculté De Médecine , Monastir , Tunisia , and
| | - Mossadok Ben-Attia
- f Laboratoire De Biosurveillance De L'environnement, Faculté Des Sciences De Bizerte , Zarzouna , Tunisia
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Drover DR, Hammer GB, Barrett JS, Cohane CA, Reece T, Zajicek A, Schulman SR. Evaluation of sodium nitroprusside for controlled hypotension in children during surgery. Front Pharmacol 2015. [PMID: 26217225 PMCID: PMC4491614 DOI: 10.3389/fphar.2015.00136] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE (1) To define the onset and offset of the blood-pressure-lowering effects of sodium nitroprusside (SNP) for use in developing instructions for dose titration in children undergoing a surgical or medical procedure, and (2) to assess the safety of SNP administration in pediatric patients requiring controlled reduction of blood pressure. METHODS We conducted a randomized, double-blind, parallel-group, dose-ranging, effect-controlled, multicenter study of intravenous (IV) infusions of SNP in pediatric patients <17 years, who required controlled hypotension for at least 2 h while undergoing a surgical or medical procedure. A blinded SNP dose of 0.3, 1, 2, or 3 μg/kg/min was infused for 30 min, followed by open-label administration for at least 90 min. Both infusions were titrated to effect. RESULTS The final intent-to-treat group comprised 203 patients. Significant reductions in mean arterial pressure (MAP) from baseline were observed for all four doses at 20 and 25 min after the start of infusion (p ≤ 0.009 and p ≤ 0.010 for each time, respectively). Overall, 98.5% of the patients achieved the target MAP; 72.9% first achieved the target MAP during the blinded infusion. The mean infusion rate at target MAP was 1.07 μg/kg/min. CONCLUSION We determined that 0.3 μg/kg/m is a reasonable starting dose for SNP in pediatric patients requiring controlled hypotension. The infusion rate can then be increased to achieve the desired reduction in blood pressure. On the basis of our results, we found an average infusion rate of 1 μg/kg/min might be appropriate. Of note, no cyanide toxicity was reported, and no measureable cyanide levels were detected in any blood samples obtained during the study. http://clinicaltrials.gov/show/NCT00135668.
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Affiliation(s)
- David R Drover
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University School of Medicine Stanford, CA, USA
| | - Gregory B Hammer
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University School of Medicine Stanford, CA, USA
| | - Jeffrey S Barrett
- Clinical Pharmacology and Therapeutics Division, The Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania Medical School Philadelphia, PA, USA
| | - Carol A Cohane
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University School of Medicine Stanford, CA, USA
| | - Tammy Reece
- Duke Clinical Research Institute, Duke University Medical Center Durham, NC, USA
| | - Anne Zajicek
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health Bethesda, MD, USA
| | - Scott R Schulman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco San Francisco, CA, USA
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3
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Abstract
OBJECTIVE Sodium nitroprusside is a direct-acting vasodilator used to lower blood pressure in the operating room and ICU. The efficacy of sodium nitroprusside has been analyzed in few pediatric randomized trials. This study assesses the efficacy and safety of sodium nitroprusside following at least 12 hours of IV infusion in children. DESIGN Randomized, double-blind withdrawal to placebo study. SETTING ICUs. PATIENTS Pediatric patients younger than 17 years. INTERVENTIONS Following 12-24 hours of open-label sodium nitroprusside titration, a blinded infusion of sodium nitroprusside or placebo was administered (at the stable rate used at the end of the open-label phase) for up to 30 minutes. MEASUREMENTS AND MAIN RESULTS The primary efficacy measure was whether control of mean arterial blood pressure was lost, that is, increased above ambient baseline for two consecutive minutes during the blinded phase. The proportion of patients who lost mean arterial blood pressure control in the placebo group (15/19; 79%) was significantly different than those in the sodium nitroprusside group (9/20; 45%) (p = 0.048). Three patients experienced rebound hypertension during the blinded phase, and all were in the placebo group. Serious adverse event rates were low (7/52; 13%), and in only one patient was the serious adverse event determined to be related to sodium nitroprusside by the site investigator. Fourteen patients (27%) had whole blood cyanide levels above 0.5 μg/mL, with high correlation (0.7) between infusion rate and cyanide levels, but there were few clinical signs of cyanide toxicity. CONCLUSIONS Sodium nitroprusside is efficacious in maintaining mean arterial blood pressure control in children following a 12-hour infusion. Although a high proportion of patients were found to have elevated cyanide levels, toxicity was not observed.
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Ennezat PV, Stewart M, Samson R, Bouabdallaoui N, Maréchaux S, Banfi C, Bouvaist H, Le Jemtel TH. Editor's Choice-Recent therapeutic trials on fluid removal and vasodilation in acute heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 5:86-95. [PMID: 25414321 DOI: 10.1177/2048872614560504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 10/14/2014] [Indexed: 01/08/2023]
Abstract
Recent therapeutic trials regarding the management of acute heart failure (AHF) failed to demonstrate the efficacy of newer therapeutic modalities and agents. Low- versus high-dose and continuous administration of furosemide were shown not to matter. Ultrafiltration was not found to be more efficacious than sophisticated diuretic therapy including dose-adjusted intravenous furosemide and metolazone. Dopamine and nesiritide were not shown to be superior to current therapy. Tezosentan and tovalptan had no effect on mortality. The development of rolofylline was terminated due to adverse effect (seizures). Lastly, preliminary experience with serelaxin indicates a mortality improvement at six months that remains to be confirmed. The disappointing findings of these recent trials may reflect the lack of efficacy of newer therapeutic modalities and agents. Alternatively the disappointing findings of these recent trials may be in part due to methodological issues. The AHF syndrome is complex with many clinical phenotypes. Failure to match clinical phenotypes and therapeutic modalities is likely to be partly responsible for the disappointing findings of recent AHF trials.
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Affiliation(s)
- Pierre V Ennezat
- Cardiology Department, Centre Hospitalier Universitaire de Grenoble, France
| | - Merrill Stewart
- Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Rohan Samson
- Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Nadia Bouabdallaoui
- Department of Cardiovascular Surgery, La Pitié Salpêtrière Hospital, Paris, France
| | - Sylvestre Maréchaux
- Groupement des Hôpitaux de l'Institut Catholique de Lille, Faculté Libre de Médecine, Cardiology Department, Université Catholique de Lille, Lille, France
| | - Carlo Banfi
- Division of Cardiovascular Surgery and Geneva Hemodynamic Research Group, Geneva University Hospitals, Geneva, Switzerland
| | - Hélène Bouvaist
- Cardiology Department, Centre Hospitalier Universitaire de Grenoble, France
| | - Thierry H Le Jemtel
- Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Hammer GB, Connolly SG, Schulman SR, Lewandowski A, Cohane C, Reece TL, Anand R, Mitchell J, Drover DR. Sodium nitroprusside is not associated with metabolic acidosis during intraoperative infusion in children. BMC Anesthesiol 2013; 13:9. [PMID: 23631460 PMCID: PMC3648371 DOI: 10.1186/1471-2253-13-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 04/16/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sodium nitroprusside (SNP) is a potent vasodilator that has been used to induce deliberate hypotension in children during surgery involving significant blood loss, including craniofacial and spinal fusion procedures. SNP metabolism liberates cyanide, which may cause interference with cellular energy metabolism, leading to metabolic acidosis and central nervous system injury. We performed a retrospective, case-control study to determine whether the short-term intra-operative use of SNP for deliberate hypotension is associated with metabolic acidosis in children undergoing surgical procedures for craniofacial or spinal anomalies. Cyanide and thiocyanate concentrations were also recorded in patients who received SNP. METHODS Data from 166 children undergoing craniofacial and spinal fusion surgery between 2005 and 2010 at Lucile Packard Children's Hospital (LPCH) at Stanford were analyzed. Records from 60 patients who received SNP (SNP group) as part of a multicenter, randomized, double-blind study were compared with records from 106 eligible patients who had blood pressure reduction using anesthetic agents and did not receive SNP (control group). Metabolic acidosis was defined as serum bicarbonate (HCO3) < 18.5 mEq/L. Whole blood CN, plasma thiocyanate and urinary thiocyanate concentrations were measured in patients in the SNP group. Differences in metabolic acidosis rates between the SNP and control groups were assessed through a test of noninferiority in the rate for the SNP group with a noninferiority threshold of 0.2. A z-test was used to test the null hypothesis. The alternative hypothesis was that the difference in these rates was less than 0.2. The same noninferiority threshold of 0.2 was also used to perform separate, secondary tests for noninferiority in the proportion of patients with HCO3 levels below 18.5 mEq/L and the proportion of patients who required HCO3 administration. RESULTS Fewer patients in the SNP group experienced metabolic acidosis compared to the control group (31.7% vs. 36.8%, respectively; p < .001). No whole blood CN levels above the lower limit of quantification were detected in any of the 51 patients with validated CN data. Plasma and urinary thiocyanate levels were also low. CONCLUSIONS Our findings suggest that SNP, when used for short-term deliberate hypotension, does not cause an increased incidence of metabolic acidosis compared with the use of anesthetic agents alone. TRIAL REGISTRATION TRIAL REGISTRATION NUMBER NCT00135668.
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Affiliation(s)
- Gregory B Hammer
- Department of Anesthesia, Stanford University School of Medicine, Stanford, USA.
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6
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Baek JG, Jeong HL, Park JS, Seo JH, Park ES, Lim JY, Park CH, Woo HO, Youn HS, Yeom JS. Successful treatment by exchange transfusion of a young infant with sodium nitroprusside poisoning. KOREAN JOURNAL OF PEDIATRICS 2010; 53:805-8. [PMID: 21189979 PMCID: PMC3004497 DOI: 10.3345/kjp.2010.53.8.805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 04/19/2010] [Accepted: 05/25/2010] [Indexed: 11/27/2022]
Abstract
Although sodium nitroprusside (SNP) is often used in pediatric intensive care units, cyanide toxicity can occur after SNP treatment. To treat SNP-induced cyanide poisoning, antidotes such as amyl nitrite, sodium nitrite, sodium thiosulfate, and hydroxycobalamin should be administered immediately after diagnosis. Here, we report the first case of a very young infant whose SNP-induced cyanide poisoning was successfully treated by exchange transfusion. The success of this alternative method may be related to the fact that exchange transfusion not only removes the cyanide from the blood but also activates detoxification systems by supplying sulfur-rich plasma. Moreover, exchange transfusion replaces cyanide-contaminated erythrocytes with fresh erythrocytes, thereby improving the blood's oxygen carrying capacity more rapidly than antidote therapy. Therefore, we believe that exchange transfusion might be an effective therapeutic modality for critical cases of cyanide poisoning.
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Affiliation(s)
- Jong Geun Baek
- Department of Pediatrics, Gyeongsang National University School of Medicine, Jinju, Korea
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Thomas C, Svehla L, Moffett BS. Sodium-nitroprusside-induced cyanide toxicity in pediatric patients. Expert Opin Drug Saf 2009; 8:599-602. [PMID: 19645589 DOI: 10.1517/14740330903081717] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sodium nitroprusside (SNP) is often used as a continuous infusion intravenous vasodilator in pediatric patients. However, cyanide toxicity can occur with SNP therapy. Scant literature is available determining the safety of SNP therapy, the incidence of cyanide toxicity or the risk factors for cyanide toxicity in pediatric patients. OBJECTIVE To review the literature concerning the safety of intravenous SNP with regard to cyanide toxicity in the pediatric patient population. METHODS A MedLine search was used to identify articles pertaining to SNP therapy and cyanide toxicity in pediatric patients. CONCLUSIONS Sodium nitroprusside seems to be safe when used in critically ill pediatric patients. Cyanide toxicity may occur in patients with specific risk factors. Routine monitoring of cyanide levels may not be warranted.
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Affiliation(s)
- Christopher Thomas
- Texas Children's Hospital, Department of Pharmacy, 6621 Fannin Street, MC 2-2510, Houston, TX 77030, USA.
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8
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Cyanide poisoning in the post-transplantation patient-a cautionary tale. Pediatr Nephrol 2008; 23:2273-5. [PMID: 18685870 DOI: 10.1007/s00467-008-0915-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Revised: 05/16/2008] [Accepted: 05/20/2008] [Indexed: 10/21/2022]
Abstract
There have been few reported cases of cyanide toxicity following treatment with sodium nitroprusside. We report on the case of a paediatric patient who had received sodium nitroprusside for intractable hypertension in the post-operative period, resulting in cyanide toxicity. Treatment with sodium thiosulphate, sodium nitrate and haemodialysis resulted in the elimination of cyanide from the circulation. The patient made a full recovery with no neurological sequelae.
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9
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Moffett BS, Price JF. Evaluation of Sodium Nitroprusside Toxicity in Pediatric Cardiac Surgical Patients. Ann Pharmacother 2008; 42:1600-4. [DOI: 10.1345/aph.1l192] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Sodium nitroprusside (SNP) is often used in postoperative pediatric cardiac surgical patients. Cyanide toxicity may occur with the use of SNP. There is a paucity of literature describing dosing parameters or physical signs and symptoms of toxicity with SNP. Objective: To determine the incidence of cyanide toxicity in postoperative pediatric cardiac surgical patients treated with SNP and identify dosing parameters and physical signs and symptoms that may predict elevated cyanide concentrations. Methods: Medical records of patients who received SNP in the pediatric cardiac intensive care unit from January 2002 through December 2002 were identified and evaluated for cyanide and thiocyanate levels, dosing, and signs and symptoms of toxicity. Patients were included if they had received SNP after cardiac surgery, were 18 years of age or less, and had at least one cyanide or thiocyanate level determined while receiving therapy. Patients were excluded if they had received sodium thiosulfate. The Mann-Whitney U test was used to determine significant differences in mean dose, duration of infusion, renal function, serum lactate, and acid-base status between groups with elevated or nonelevated levels. Logistic regression and receiver operator curve were used to determine variables associated with elevated levels. Relationships between signs and symptoms of toxicity and elevated levels were evaluated with Fisher's exact test. Results: Cyanide concentrations were in the toxic range in 7 of 63 (11%) patients. Patients with elevated concentrations had significantly higher mean dose, cumulative dose, and acid-base excess values. Elevated cyanide levels were independently predicted by mean dose, cumulative dose, and acid-base excess values, and a dose of 1.8 μg/kg/min predicted an elevated cyanide concentration with 89% sensitivity and 88% specificity. Adverse events were not reliable predictors of elevated cyanide levels. Conclusions: Mean dose of SNP is the best predictor of elevated cyanide levels. Adverse events commonly associated with cyanide toxicity may not be reliable indicators of elevated cyanide concentrations.
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Affiliation(s)
| | - Jack F Price
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston
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López-Herce J, Borrego R, Bustinza A, Carrillo A. Elevated carboxyhemoglobin associated with sodium nitroprusside treatment. Intensive Care Med 2005; 31:1235-8. [PMID: 16041521 DOI: 10.1007/s00134-005-2718-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2005] [Accepted: 06/21/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To report four cases of carboxyhemoglobinemia associated with high doses of sodium nitroprusside after cardiac transplant in children. PATIENTS Four children in the pediatric care unit of a university hospital aged 6 months-4 years. Carboxyhemoglonemia developed at levels of 5.5-7.7% in patients receiving high doses of sodium nitroprusside (7-16 microg/kg per minute and no other medication that could caused elevated carboxyhemoglobin). One patient died, and three recovered with no sequelae after discontinuation of sodium nitroprusside. CONCLUSIONS High doses of sodium nitroprusside can induce carboxyhemoglobinemia in children after heart transplant, probably by inducing hemeoxygenase, with no other secondary effects.
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Affiliation(s)
- Jesús López-Herce
- Pediatric Critical Care Unit, Gregorio Marañón University Hospital, Dr. Castelo 47, 28009 Madrid, Spain.
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11
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Tweddell JS, Hoffman GM. Postoperative management in patients with complex congenital heart disease. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 5:187-205. [PMID: 11994879 DOI: 10.1053/pcsu.2002.31499] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Life-threatening problems occur in the neonate and infant after cardiac surgery because of the interplay of diminished cardiac output (CO), increased metabolic demand, inflammatory responses to cardiopulmonary bypass, and maladaptive responses to stress. Therefore, the postoperative management of patients with complex congenital heart defects is directed at optimization of oxygen delivery to maintain end-organ function and promote wound healing. Traditionally, assessment of circulation in the postoperative congenital heart patient has depended on indirect assessment of CO using parameters such as blood pressure, pulses, capillary refill, and urine output. Because of the limitations of indirect and observer-dependent assessment of CO, we rely on objective measures of tissue oxygen levels for the complex postoperative patient. We have found that continuous monitoring of the mixed venous saturation (SvO2) allows for identification of acute changes in systemic oxygen delivery and frequently precedes other indicators of decreased CO. The postoperative patient can be expected to have a period of decreasing CO, and the need for intervention should be anticipated because critical low output syndrome will develop in a subset of patients. Strategies for postoperative care are developed based on the diagnosis and procedure, but optimizing SvO2 is a consistent goal. A uniform approach to airway maintenance, vascular access, and drug infusions, all universal concerns during the perioperative period, minimizes the potential for these predictable and necessary interventions to result in morbidity or mortality. Management of the postoperative single ventricle patient targets stabilization of the systemic vascular resistance through the use of vasodilators to improve systemic perfusion and simplify ventilator management. Management of any individual patient should be driven by objective analysis of available data and must include efforts to re-evaluate the treatment plan as well as to identify unanticipated problems.
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Affiliation(s)
- James S Tweddell
- Divisions of Cardiothoracic Surgery, Pediatric Anesthesia, and Critical Care, The Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
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Flynn JT, Mottes TA, Brophy PD, Kershaw DB, Smoyer WE, Bunchman TE. Intravenous nicardipine for treatment of severe hypertension in children. J Pediatr 2001; 139:38-43. [PMID: 11445792 DOI: 10.1067/mpd.2001.114030] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine the effect of intravenous nicardipine in the treatment of children with severe hypertension. METHODS The medical records of 29 children (mean age 94 months) treated with intravenous nicardipine were retrospectively reviewed. The mean duration of severe hypertension before nicardipine use was 12.5 hours. Most (74%) patients were receiving other antihypertensive agents before nicardipine. RESULTS The initial nicardipine dose was 0.8 +/- 0.3 microg/kg/min (mean +/- SD). The mean effective dose was 1.8 +/- 1.0 microg/kg/min (range, 0.3 to 4.0). Blood pressure control was achieved within 2.7 +/- 2.1 hours after nicardipine was started. Nicardipine treatment produced a 16% reduction in systolic blood pressure, a 23% reduction in diastolic blood pressure, and a 7% increase in heart rate. Nicardipine was effective as a single agent on 26 (84%) of 31 occasions. Adverse effects included tachycardia, flushing, palpitations, and hypotension. CONCLUSIONS When administered in the intensive care unit setting with close patient monitoring, intravenous nicardipine effectively lowered blood pressure in children with severe hypertension. Larger prospective studies should be conducted to confirm these findings.
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Affiliation(s)
- J T Flynn
- Division of Pediatric Nephrology, Department of Pediatrics and Communicable Diseases, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, USA
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Kurimoto M, Endo S, Hirashima Y, Hamada H, Ogiichi T, Takaku A. Growth inhibition and radiosensitization of cultured glioma cells by nitric oxide generating agents. J Neurooncol 1999; 42:35-44. [PMID: 10360477 DOI: 10.1023/a:1006160305294] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The authors examined the effect of nitric oxide (NO) generating agents on the growth and radiosensitivity of cultured glioma cells. Three glioma, rat C6, and human T98G and U87 cell lines were treated with the NO generating agents, S-nitroso-N-acetyl-penicillamine (SNAP) or sodium nitroprusside (SNP). These agents released NO in the cell culture media and inhibited the growth of the glioma cells. Growth-inhibition was attenuated by hemoglobin, a known inhibitor of NO, suggesting it is mediated by NO. When C6 and T98G cells were irradiated in the presence of SNAP or SNP at 100 microM, radiosensitization was observed. SNAP at 100 microM exhibited a sensitizer enhancement ratio (SER) of 1.4 for C6 cells and 1.8 for T98G cells. SNP at 100 microM only radiosensitized T98G cells with a SER of 1.9. The effect of SNP on radiosensitization of C6 cells was unclear. We conclude that NO generating agents are potential growth inhibitors and radiosensitizers for malignant glioma cells. NO mediated radiosensitization of glioma cells by NO generating agents may offer a new therapeutic approach for malignant glioma.
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Affiliation(s)
- M Kurimoto
- Department of Neurosurgery, Toyama Medical and Pharmaceutical University, Japan
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14
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Abstract
Children presenting with hypertension should be considered for emergency treatment when there is evidence of end-organ toxicity. Complications of extreme hypertension may be very serious, even life threatening, with the potential for life-long sequelae. Of greatest significance is damage to the central nervous system. Treatment of hypertensive emergencies should be directed toward the lowering of blood pressure enough to reduce toxicity, but not at a rate likely to cause hypoperfusion of vital organs. This blood pressure reduction should, in general, be carefully controlled in an intensive care unit, with attention to central nervous system, cardiac, and renal function. Intravenous agents are preferable under these circumstances, due to greater ease in modulating blood pressure. In the absence of specific contraindications, a continuous infusion of nicardipine or sodium nitroprusside is preferable. Intravenous labetalol by bolus injection, followed by continuous infusion, also may be used. Oral agents should be reserved for circumstances in which symptoms of end-organ toxicity are mild or absent. Since general pediatricians have limited experience with the treatment of hypertensive emergencies, consultation with physicians experienced in treating hypertensive emergencies is suggested when possible.
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Affiliation(s)
- T Groshong
- Department of Child Health, University of Missouri, Columbia 65212, USA
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15
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Przybylo HJ, Stevenson GW, Hall SC. Sodium Nitroprusside Metabolism in Children. Anesth Analg 1996. [DOI: 10.1213/00000539-199606000-00042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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16
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Sodium Nitroprusside Metabolism in Children. Anesth Analg 1996. [DOI: 10.1097/00000539-199606000-00042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Przybylo HJ, Stevenson GW, Schanbacher P, Backer C, Dsida RM, Hall SC. Sodium Nitroprusside Metabolism in Children During Hypothermic Cardiopulmonary Bypass. Anesth Analg 1995. [DOI: 10.1213/00000539-199511000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Przybylo HJ, Stevenson GW, Schanbacher P, Backer C, Dsida RM, Hall SC. Sodium nitroprusside metabolism in children during hypothermic cardiopulmonary bypass. Anesth Analg 1995; 81:952-6. [PMID: 7486083 DOI: 10.1097/00000539-199511000-00010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Ten children, aged 1-7 yr, presenting for repair of complex congenital heart lesions, were prospectively studied. A ketamine, halothane/isoflurane, and fentanyl anesthetic was used. After initiation of hypothermic cardiopulmonary bypass, sodium nitroprusside (SNP) was titrated as necessary to maintain a target mean arterial blood pressure of 35-60 mm Hg. Blood samples drawn immediately prior to starting SNP infusion, every 15 min during infusion, and at 1, 4, and 24 h postinfusion were analyzed for whole blood cyanide (CN-) and serum thiocyanate (SCN-). Blood gas analysis was performed every 30 min during SNP infusion. A maximum CN- level > or = 1.0 micrograms/mL was observed in two children; four others had maximum CN- levels between 0.5 micrograms/mL and 1.0 micrograms/mL (normal, < 0.2 micrograms/mL). No child had a clinically important increase of SCN- subsequent to SNP infusion. There was substantial variability in observed CN- accumulation during SNP infusion. CN- levels during the first 60 min correlated with the average SNP rate of administration (P = 0.02). Cyanide levels rapidly decreased after termination of SNP infusion and were undetectable 4 h postinfusion. Despite the short-term increase of CN- level, no child showed biochemical signs of toxicity (acidosis or increased mixed venous oxygen tension).
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Affiliation(s)
- H J Przybylo
- Department of Pediatric Anesthesia, Children's Memorial Hospital, Northwestern University Medical School, Chicago, Illinois 60614, USA
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Williams RS, Mickell JJ, Young ES, Shapiro JH, Lofland GK. Methemoglobin levels during prolonged combined nitroglycerin and sodium nitroprusside infusions in infants after cardiac surgery. J Cardiothorac Vasc Anesth 1994; 8:658-62. [PMID: 7880995 DOI: 10.1016/1053-0770(94)90198-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Nitroglycerin (NTG) and sodium nitroprusside (SNP) are routinely used perioperatively in infants with congenital heart defects. In this study, NTG and SNP were infused in the operating room to increase venous capacitance, reduce systemic and pulmonary afterload, facilitate weaning off cardiopulmonary bypass, stabilize hemodynamics for transport to the intensive care unit (ICU), and reduce the fluid resuscitation needed upon arrival in the ICU. Because of the risk for accumulation of methemoglobin (MetHb) and cyanmethemoglobin (cyan-MetHb) during prolonged continuous infusion of NTG and SNP, it was decided to (1) quantify ICU use, (2) measure % MetHb at 12-hour intervals, and (3) look indirectly for the accumulation of cyan-MetHb by comparing simultaneous pulse oximetry (SpO2) (Nellcor N-100 [Nellcor, Haywood, CO]) and CO-oximetry (SaO2) (Corning 270 [Corning, Medfield, MA]). A total of 69 arterial samples were obtained from 16 infants (median age 4.4 months) following cardiac surgery with bypass. Median doses of NTG, 6.0 mg/kg (range 0.7 to 27.5), and SNP, 3.3 mg/kg (range 0.6 to 33.4), were infused over a median of 64.5 hours (range 12 to 183) (N = 16 patients). The median MetHb was 0.6% (range 0.0 to 1.5) after infusions of NTG, 1.8 micrograms/kg/min (range 0.5 to 4), and SNP, 1.3 micrograms/kg/min (range 0.3 to 8.4) (N = 69 measurements). Regression analysis of oximetry data yielded the equation: SpO2 = 1.04 SaO2 - 3.7%, r = 0.97. The mean difference between SpO2 and SaO2 data pairs was 0.0% (bias) with a SD (precision) of +/- 2.3%.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R S Williams
- Department of Pediatrics, Children's Medical Center, Medical College of Virginia, Virginia Commonwealth University, Richmond
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Abstract
This review summarizes the current approach to antihypertensive therapy in children. It focuses on newer drugs, taking into account changes in clinical practice that have occurred since publication of the second Task Force report. Non-pharmacological therapy, including weight reduction, exercise, and dietary intervention, has great potential for the effective reduction of blood pressure. It should be introduced not only in patients with "significant" hypertension, but also in the care of patients with high normal blood pressure and to complement drug therapy for patients with "severe" hypertension. The goal of antihypertensive drug therapy is reduction of blood pressure to a level below the 95th percentile for age and sex. Attempts to rapidly achieve normal blood pressure immediately after starting therapy are contraindicated. The objective of emergency treatment is prevention of hypertension-related adverse events, and this usually requires only a modest reduction in blood pressure. Nifedipine has become the most commonly used drug for emergency treatment of asymptomatic children. Exceptionally severe elevations of blood pressure or the presence of symptoms should be treated with more potent intravenous drugs. The converting enzyme inhibitors and calcium channel blockers currently are the primary agents for chronic treatment of hypertension in children. Diuretics are usually reserved for hypertensive patients with renal disease. beta-Adrenergic blocking drugs also are effective but have a number of potential adverse effects. Prazosin generally is used as a second-line agent, if the above-noted drugs are ineffective. Although minoxidil is still one of the most effective antihypertensive agents, its associated adverse effects have limited its usefulness.
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Affiliation(s)
- A R Sinaiko
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis 55455
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Abstract
A hypertensive crisis can be caused by many factors. Frequently, the mechanism involved is complex and highly variable among patients. Without drug therapy, this condition is associated with very high mortality and morbidity. There are a number of oral and intravenous hypotensive agents available, which can effectively control blood pressure in a hypertensive crisis. The relative advantages and disadvantages of each treatment option is discussed.
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Affiliation(s)
- D S McKindley
- Department of Clinical Pharmacy, University of Tennessee, Memphis
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