Ø  1 mg/mL injection

Ø  Acute Hypotension

·         Adult

a.       Initial: 8-12 mcg/minute intravenous (IV) infusion; titrate to effect

b.      Maintenance: 2-4 mcg/minute IV infusion

Ø  Cardiac Arrest

·         Adult

a.       Initial: 8-12 mcg/minute intravenous (IV) infusion; titrate to effect

b.      Maintenance: 2-4 mcg/minute IV infusion

Ø  Sepsis and Septic Shock

·         Adult

a.       0.01-3 mcg/kg/minute intravenous (IV) infusion

Classification

Ø  Autonomic nervous system agent; alpha- and beta-adrenergic agonist (sympathomimetic)

Ø  Direct-acting sympathomimetic amine identical to body catecholamine norepinephrine. Acts directly and predominantly on alpha-adrenergic receptors; little action on beta receptors except in heart (beta1 receptors). Vasoconstriction and cardiac stimulation; also powerful constrictor action on resistance and capacitance blood vessels. Therapeutic Effects, Peripheral vasoconstriction and moderate inotropic stimulation of heart result in increased systolic and diastolic blood pressure, myocardial oxygenation, coronary artery blood flow, and work of heart.

Ø  To restore BP in certain acute hypotensive states such as shock, sympathectomy, pheochromocytomectomy, spinal anesthesia, poliomyelitis, MI, septicemia, blood transfusion, and drug reactions. Also as adjunct in treatment of cardiac arrest.

Ø  Hypersensitivity

Ø  Low blood pressure (hypotension) due to blood volume deficit

Ø  Peripheral vascular thrombosis (except for lifesaving procedures)

Ø  Concomitant use with some general anesthetics: Chloroform, trichloroethylene, cyclopropane, halothane

6.       Side Effects and Adverse Effects

Ø  CNS: Headache, anxiety

Ø  CV: Bradycardia, severe hypertension, arrhythmias, palpitations

Ø  Respiratory: Respiratory difficulty, shortness of breath

Ø  Skin: Irritation with extravasation, necrosis

Ø  Others: Ischemic injury, nausea, anginal pain, fever

Ø  Monitor constantly while patient is receiving norepinephrine. Take baseline BP and pulse before start of therapy, then q2min from initiation of drug until stabilization occurs at desired level, then every 5 min during drug administration.

Ø  Adjust flow rate to maintain BP at low normal (usually 80–100 mm Hg systolic) in normotensive patients. In previously hypertensive patients, systolic is generally maintained no higher than 40 mm Hg below preexisting systolic level.

Ø  Observe carefully and record mental status (index of cerebral circulation), skin temperature of extremities, and color (especially of earlobes, lips, nail beds) in addition to vital signs.

Ø  Monitor I&O. Urinary retention and kidney shutdown are possibilities, especially in hypovolemic patients. Urinary output is a sensitive indicator of the degree of renal perfusion. Report decrease in urinary output or change in I&O ratio.

Ø  Be alert to patient's complaints of headache, vomiting, palpitation, arrhythmias, chest pain, photophobia, and blurred vision as possible symptoms of overdosage. Reflex bradycardia may occur as a result of rise in BP.

Ø  Continue to monitor vital signs and observe patient closely after cessation of therapy for clinical sign of circulatory inadequacy.

Ø  0.5 mg/mL, 5 mg/mL, 10 mg/mL injection; 

Ø  0.3 mg, 0.4 mg, 0.6 mg sublingual tablets; 

Ø  0.4 mg/spray translingual spray; 

Ø  2 mg, 3 mg buccal tablets; 

Ø  2.5 mg, 6.5 mg, 9 mg, 13 mg sustained-release tablets, capsules; 

Ø  0.1 mg/h, 0.2 mg/h, 0.3 mg/h, 0.4 mg/h, 0.6 mg/h, 0.8 mg/h transdermal patch

Ø  Cardiovascular agent; nitrate vasodilator

Ø  Organic nitrate and potent vasodilator that relaxes vascular smooth muscle by an unknown mechanism, resulting in dose-related dilation of both venous and arterial blood vessels. Promotes peripheral pooling of blood, reduction of peripheral resistance, and decreased venous return to the heart. Both left ventricular preload and afterload are reduced and myocardial oxygen consumption or demand is decreased.

Ø  Nitroglycerin is indicated for various purposes. It is indicated to prevent and treat angina or chest pain due to cardiovascular disease, as well as to treat peri-operative hypertension or induce intra-operative hypotension. It is also indicated to treat acute heart failure in patients with myocardial infarction. In the ointment form, nitroglycerin is indicated to treat pain caused by anal fissures. The transdermal form is applied directly to the skin to prevent acute anginal attacks.

Contraindications

Ø  PDE-5-Inhibitors And sGC-Stimulators

Ø  Severe Anemia

Ø  Increased Intracranial Pressure

Ø  Hypersensitivity

Ø  Circulatory Failure And Shock

Ø  CNS: Headache, apprehension, blurred vision, weakness, vertigo, dizziness, faintness.

Ø  CV: Postural hypotension, palpitations, tachycardia (sometimes with paradoxical bradycardia), increase in angina, syncope, and circulatory collapse.

Ø  GI: Nausea, vomiting, involuntary passing of urine and feces, abdominal pain, dry mouth. Hematologic: Methemoglobinemia (high doses). 

Ø  Skin: Cutaneous vasodilation with flushing, rash, exfoliative dermatitis, contact dermatitis with transdermal patch; topical allergic reactions with ointment: pruritic eczematous eruptions, anaphylactoid reaction characterized by oral mucosal and conjunctival edema. 

Ø  Body as a Whole: Muscle twitching, pallor, perspiration, cold sweat; local sensation in oral cavity at point of dissolution of sublingual forms.

Nursing Responsibilities

Ø  Administer IV nitroglycerin with extreme caution to patients with hypotension or hypovolemia since the IV drug may precipitate a severe hypotensive state.

Ø  Monitor the patient closely for changes in levels of consciousness and for dysrhythmias. IV nitroglycerin solution contains a substantial amount of ethanol as a diluent. Ethanol intoxication can develop with high doses of IV nitroglycerin (vomiting, lethargy, coma, breath smells of alcohol). If intoxication occurs, the infusion should be stopped promptly; the patient recovers immediately with discontinuation of drug administration.

Ø  Assess for headaches. Approximately 50% of all patients experience mild to severe headaches following nitroglycerin. The transient headache usually lasts about 5 min after sublingual administration and seldom longer than 20 min. Assess the degree of severity and consult as needed with a physician about analgesics and dosage adjustment.

Ø  Take baseline BP and heart rate with the patient in sitting position before initiation of treatment with transdermal preparations.

Ø  One hour after transdermal (ointment or unit) medication has been applied, check BP and pulse again with the patient in sitting position. Report measurements to a physician.

Ø  Assess for and report blurred vision or dry mouth.

Ø  Assess for and report the following topical reactions. Contact dermatitis from the transdermal patch; pruritus and erythema from the ointment.
Ø Be aware that local burning or tingling from the sublingual form has no clinical significance. 

https://www.rxlist.com/nitrostat-drug.htm#description