Cardiovascular Critical Care II
Medication
Indication
Special Consideration
Nitroprusside
Most indications
(exclusions: ICP
elevation, coronary
infarction/ischemia)
Liver failure – cyanide accumulation
Renal failure – thiocyanate accumulation
Can draw serum cyanide and thiocyanate concentrations to monitor
Toxicity associated with prolonged infusions (> 72 hr) or high doses
(> 3 mcg/kg/min)
May result in coronary steal
Increases ICP
Hydralazine
Pregnancy
Can result in prolonged hypotension (less predictable dose response)
Risk of reflex tachycardia
Headaches, lupus-like syndrome (with long-term use)
Nicardipine
Most indications,
especially acute
ischemic or
hemorrhagic stroke
Risk of reflex tachycardia
Infusion can lead to large fluid volumes administered
Clevidipine
Most indications,
especially acute
ischemic or
hemorrhagic stroke
Formulated in oil-in-water formulation providing 2 kcal/mL of lipid calories
Caution for patients allergic to soy or eggs
Nitroglycerin
Coronary ischemia/
infarction
Acute left
ventricular failure
Pulmonary edema
Tachyphylaxis occurs rapidly, requiring dose titrations
Adverse effects: Flushing, headache, erythema; often dose-limiting adverse
effects
Veno > arterial vasodilator
Esmolol
Aortic dissection
Coronary ischemia/
infarction
Contraindicated in acute decompensated heart failure, bradycardia
Should be used in conjunction with an arterial vasodilator for BP management
in aortic dissection (initiate esmolol first because of the delayed onset
relative to vasodilators such as nitroprusside)
Metabolism is organ-independent (hydrolyzed by esterases in blood)
Useful in tachyarrhythmias
Metoprolol
Aortic dissection
Coronary ischemia/
infarction
Contraindicated in acute decompensated heart failure, bradycardia, heart
block
Should be used in conjunction with an arterial vasodilator for BP manage-
ment in aortic dissection (initiate metoprolol first because of the delayed
onset relative to vasodilators such as nitroprusside)
Useful in tachyarrhythmias
Labetalol
Aortic dissection
Coronary ischemia/
infarction
Pregnancy
May be used as monotherapy in acute aortic dissection
Contraindicated in acute decompensated heart failure, reactive airway
disease
Prolonged hypotension and/or bradycardia may be experienced with over-
treatment; dose cautiously