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South Australian Neonatal Medication Guidelines 

Sodium Nitroprusside 
 50mg/2mL ampoule 

  Department for Health and Wellbeing, Government of South Australia. All rights reserved. 
 

INFORMAL COPY WHEN PRINTED  Page 1 of 5 

Public-I4-A1 
 
 

Note:
This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and facilitate 
standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based on a review of 
published evidence and expert opinion.  
Information in this statewide guideline is current at the time of publication.  
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not 
sponsor, approve or endorse materials on such links. 
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and 
professionally assess the applicability of the relevant guideline to that clinical situation. 
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the 
patient s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline. 
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are 
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful 
confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining standards of 

professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 

This is a High Risk Medication  
An overdose can be rapidly fatal. 

 

Consult Paediatric Intensive Care prior to use 

Dose and Indications 

Acute Treatment of Hypertensive Emergencies  
Acute Afterload Reduction in Refractory Congestive Heart Failure 

Intravenous Infusion 

Initially 0.25 to 0.5microgram/kg/minute, increase cautiously in steps of 0.2microgram/kg/min 
as required according to clinical response. Usual maintenance dose 2microgram/kg/minute 

Maximum dose: 6microgram/kg/minute. Caution with prolonged use at high doses. 

 

 

 

 

 

 



South Australian Neonatal Medication Guidelines 

Sodium Nitroprusside 
 50mg/2mL ampoule 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 2 of 5 

Public-I4-A1 
 
 

Preparation and Administration 

Intravenous Infusion 
Dilution may depend on the dose and fluid requirement.  

&gt; Sodium nitroprusside is diluted with compatible fluid to a concentration of between 
50microgram/mL to 200microgram/mL. Sodium Nitroprusside Concentration Selection 
Tables can be found on the following pages of this guideline to assist prescribers to gauge 
which strength is best for the patient. 

&gt; In fluid restricted patients, concentrations of up to 1000microgram/mL (1mg/mL) in glucose 
5% have been used. 

&gt; Sodium nitroprusside decomposes when exposed to light - Protect infusion solution 
from light by covering syringe with aluminium foil or black plastic  

&gt; Once diluted, sodium nitroprusside solution is a faint brown colour. Discard the solution if it 
is blue, green or dark/bright red in colour or if particles are present.  

 
There are TWO STEPS to this process.  

STEP ONE: Dilute 2mL (50mg/2mL) of sodium nitroprusside with 3mL of water for injection 
(to a total of 5mL). This makes a 10mg/mL solution  

STEP TWO: Dilute the appropriate volume of the 10mg/mL sodium nitroprusside solution 
using compatible fluid; and administer by continuous infusion. Diluted preparation is stable for 
24 hours at room temperature (must be protected from light). 

The two standard strengths used are:  

? Sodium nitroprusside 100microgram/mL 

? Sodium nitroprusside 200microgram/mL 

 

Formulae 

To calculate infusion rate (mL/hr): 

Rate (mL/hr) = 60 x dose (microgram/kg/min) x weight(kg)  

   Strength (microgram/mL) 

To calculate the dose (microgram/kg/min): 
Dose (microgram/kg/min) = Rate (mL/hr) x Strength (microgram/mL) 

      60 x Weight (kg) 
 
 
 
 
 



South Australian Neonatal Medication Guidelines 

Sodium Nitroprusside 
 50mg/2mL ampoule 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 3 of 5 

Public-I4-A1 
 
 

TO MAKE 50mL SYRINGE: 

Sodium Nitroprusside 100microgram/mL  
There are TWO STEPS to this process.  
STEP ONE: Dilute 2mL (50mg/2mL) of sodium nitroprusside with 3mL of water for injection 
(to a total of 5mL). This makes a 10mg/mL solution 
STEP TWO: Dilute 0.5mL sodium nitroprusside (10mg/mL) with 49.5mL of glucose 5% 
injection. This makes a 100microgram/mL solution. 

Rate (mL/hr) 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Rate (mL/hr) 
Weight (kg) Approximate microgram/kg/minute Weight (kg) 

1 0.33 0.5 0.67 0.83 1 1.17 1.33 1.5 1.67 1 
1.5 0.22 0.33 0.44 0.56 0.67 0.78 0.89 1 1.11 1.5 
2 0.17 0.25 0.33 0.42 0.5 0.58 0.67 0.75 0.83 2 

2.5 0.13 0.2 0.27 0.33 0.4 0.47 0.53 0.6 0.67 2.5 
 

Sodium Nitroprusside 200microgram/mL 
There are TWO STEPS to this process.  
STEP ONE: Dilute 2mL (50mg/2mL) of sodium nitroprusside with 3mL of water for injection 
(to a total of 5mL). This makes a 10mg/mL solution 
STEP TWO: Dilute 1mL sodium nitroprusside (10mg/mL) with 49mL of glucose 5% injection. 
This makes a 200microgram/mL solution. 

Rate (mL/hr) 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Rate (mL/hr) 
Weight (kg) Approximate microgram/kg/minute Weight (kg) 

1 0.67 1 1.33 1.67 2 2.33 2.67 3 3.33 1 
1.5 0.44 0.67 0.89 1.11 1.33 1.56 1.78 2 2.22 1.5 
2 0.33 0.5 0.67 0.83 1 1.17 1.33 1.5 1.67 2 

2.5 0.27 0.4 0.53 0.67 0.8 0.93 1.07 1.2 1.33 2.5 
3 0.22 0.33 0.44 0.56 0.67 0.78 0.89 1 1.11 3 

3.5 0.19 0.29 0.38 0.48 0.57 0.67 0.76 0.86 0.95 3.5 

Compatible Fluids 
Glucose 5%, sodium chloride 0.9%  

 

 

 

 



South Australian Neonatal Medication Guidelines 

Sodium Nitroprusside 
 50mg/2mL ampoule 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 4 of 5 

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Adverse Effects 

Common 
Vomiting, sweating, muscle twitching 

Infrequent 
Severe hypotension, hypothyroidism, rash, flushing, increased intracranial pressure 

Rare 
Thrombocytopenia, methaemoglobinaemia, phlebitis 

Toxicity may occur, particularly with prolonged infusion or higher than recommended dose, 
due to accumulation of cyanide or thiocyanate 

Signs of cyanide toxicity include tachycardia, arrhythmia, metabolic acidosis, dilate pupils, 
pink skin, absent reflexes and decreased oxygen saturations 

Thiocyanate toxicity is associated with dyspnoea and ataxia 

Monitoring 
&gt; Continuous intra-arterial blood pressure during infusion  

&gt; Monitor for signs of toxicity (as above) 

&gt; There should be a high level of suspicion of cyanide toxicity.  If there is suspicion of 
cyanide toxicity, action should be taken immediately (see practice points).   

&gt; Monitor thiocyanate levels if prolonged therapy, doses of greater than 2microgram/kg/min, 
or with renal dysfunction 

&gt; NOTE: There is a long processing time for these levels as they are sent 
interstate and so utility is limited 

Practice Points 
&gt; The efficacy and safety of sodium nitroprusside in neonates has not been well established. 

Clinical experience is limited. 

&gt; Contraindicated in treatment of compensatory hypertension due to AV shunting or 
coarctation of the aorta. 

&gt; Caution in use with patients with increased intracranial pressure. 

&gt; Avoid sudden withdrawal   terminate infusion over 15 to 30minutes to prevent rebound 
hypertension. 

&gt; Do not mix sodium nitroprusside with any other medications.  

&gt; Extravasation may cause irritation, rash, flushing, reddening of the skin at the injection site 
and venous streaking. 

&gt; Sodium nitroprusside is rapidly metabolised to cyanide. Cyanide is further metabolised to 
thiocyanate in the liver and requires the presence of thiosulfate. Thiocyanate is then 
renally excreted. 

&gt; Renal impairment may reduce excretion of thiocyanate and increase risk of toxicity. 



South Australian Neonatal Medication Guidelines 

Sodium Nitroprusside 
 50mg/2mL ampoule 
 

 

 
INFORMAL COPY WHEN PRINTED  Page 5 of 5 

Public-I4-A1 
 
 

&gt; Patients with hepatic dysfunction are at increased risk of cyanide poisoning. Avoid use in 
severe hepatic impairment. 

&gt; Infants are particularly susceptible to cyanide toxicity 

&gt; If signs of cyanide toxicity appear: 
&gt; Discontinue sodium nitroprusside infusion 

&gt; Consult Poisons Information Centre 

&gt; Initially, administer hydroxocobalamin 50mg/kg, intravenously over 30minutes 

&gt; Cyanokit  (SAS) availability may depend on hospital site. 
Reconstitute Cyanokit  (hydroxocobalamin 5g) vial with 200mL 
compatible fluid (sodium chloride 0.9% or glucose 5%) 

&gt; Followed by administration of sodium thiosulfate 400mg/kg, intravenously 
over 10minutes 

&gt; Availability may depend on hospital site 

&gt; The paediatric dose of hydroxocobalamin as an antidote in cyanide poisoning has not 
been determined, but an initial dose has been suggest by Toxicology Handbook 

&gt; Renal haemodialysis may be used to eliminate thiocyanate if severe toxicity occurs 

Reference 
&gt; William E. Benitz, Natalie Malachowski, Ronald S. Cohen et al, Use of sodium 

nitroprusside in neonates: Efficacy and safety, The Journal of Pediatrics, 1985, vol 106, 
issue 1, pp 102-110 

&gt; Murray L, Daly F, Little M, Cadogan M. Toxicology handbook. Sydney: Elsevier Australia, 
Churchill Livingstone; 2011. 
 

Document Ownership &amp; History 
Developed by: SA Maternal, Neonatal &amp; Gynaecology Community of Practice 
Contact: Health.NeoMed@sa.gov.au 
Endorsed by:  SA Health Safety and Quality Strategic Governance Committee 
Next review due:   03/04/2025 
ISBN number:  978-1-76083-178-3 
PDS reference:  CG334 
Policy history: Is this a new policy (V1)?  Y  
 Does this policy amend or update and existing policy?  N 
 If so, which version? 
 Does this policy replace another policy with a different title?  N 
 If so, which policy (title)? 
 

Approval 
Date Version 

Who approved New/Revised 
Version Reason for Change 

03/04/2020  V1 SA Health Commissioning and Performance Division Original version 

 
 
 



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