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Nitroprusside
Abstract
Sodium nitroprusside has proved to be the most effective and best-tolerated vasodilator drug available for the management of acute hypertension, heart failure, and other vasoconstricted states as well as for the induction of controlled hypotension during surgery. It dilates both arteries and veins, has a rapid onset and offset of action, and is almost uniformly effective in achieving the desired degree of dilation by careful dosage titration. The need for close monitoring of its intravenous administration and the potential toxicity of prolonged infusions limit its general use from periods of hours to a few days, but its unique and usually well-maintained vascular actions make it an ideal agent for short-term therapy and a potentially useful model for development of new, orally effective vasodilator drugs.
... 4,8,9 The latter requires a central venous access or a large bore peripheral vein, higher doses of the drug, and may lead to frequent unpleasant systemic side effects, which limits its use, especially in patients with reactive airway disease and advanced conduction disorders. [10][11][12][13] Sodium nitroprusside is a potent vasodilator which has no effect on myocardial contractility, nonvascular smooth muscles, [14][15][16] and has been extensively used during the non-reflow phenomenon complicating percutaneous coronary angioplasty. 17,18 It has several advantages over adenosine. ...
Background
Coronary fractional flow reserve (FFR) determination is a valuable tool for the assessment of stenosis significance in intermediate coronary obstructions. Maximal hyperemia is mandatory for this determination. Although intravenous (IV) Adenosine is the standard agent used, its use carries an elevated incidence of side effects. Intracoronary sodium nitroprusside (IC NTP) is a very well-known coronary vasodilator, but it is not routinely used for FFR determinations.
Objectives
The purpose of the present study was to compare FFR determinations and side effect profile of IC NTP with IV Adenosine.
Methods
We prospectively assessed FFR determinations in a total of 20 intermediate coronary artery stenotic lesions in 18 consecutive patients with the administration of IV Adenosine (140 μg/kg/min) and IC NTP (100 μg). The appearance of side effects was registered.
Results
The mean age was 55.5 ± 7.5 years. Fifteen (83%) of the patients were male. Mean FFR values with IC NTP were similar to those obtained with IV Adenosine (0.82 ± 0.07 vs 0.82 ± 0.06, respectively, r = 0.775, p < 0.0001). Intravenous Adenosine induced side effects in 45% of patients (shortness of breath 30%, flushing 5%, headache 5%, angina pectoris 5%, and transient conduction disturbances 10%). No side effects were reported with IC NTP.
Conclusions
IC NTP at a dose of 100 μg is as effective as IV Adenosine for FFR assessment. Besides, it is better tolerated and should be consider as a vasodilator agent in the assessment of FFR.
... Regadenoson has been shown to achieve hyperemia comparable to adenosine in both canine models and humans (18)(19)(20). Sodium nitroprusside is a potent vasodilator which has no effects on myocardial contractility or nonvascular smooth muscles (21). IC nitroprusside has previously been shown to produce equivalent coronary hyperemic response when compared to IC adenosine (22). ...
Background:
FFR is useful in defining the physiological significance of intermediate coronary stenosis and requires induction of maximal hyperemia and measurement of pressure proximal and distal to the stenosis. Hyperemia normally is induced by either IV or IC adenosine, a medication associated with short-term side effects. IV regadenoson and IC nitroprusside have been suggested as viable alternatives. This meta-analysis aims to identify all studies comparing use of intravenous (IV) regadenoson or intracoronary (IC) nitroprusside with IV adenosine to determine differences related to the agent utilized for assessment of fractional flow reserve (FFR).
Methods:
We searched PubMed, EMBASE, Web of Science, SCOPUS, ClinicalTrials.gov and the Cochrane Library databases for studies comparing IV regadenoson or IC nitroprusside to IV adenosine for FFR assessment. The main outcome was difference in mean FFR measurement. The main secondary outcomes were composite side-effect profile and reclassification of lesions.
Results:
Seven studies were included in the analysis, with a total of 375 patients. Compared to IV adenosine, there was no difference in the mean FFR derived from IV regadenoson (p=1.0) or IC nitroprusside (p=0.48). IV regadenoson was associated with 53% lower risk of pooled side effects compared to IV adenosine (p=0.05). IC nitroprusside was associated with 97% lower risk of pooled side effects compared to IV adenosine (p<0.001).
Conclusions:
IV regadenoson and IC nitroprusside produce similar pressure-derived FFR measurements compared to IV adenosine and have a favorable side effect profile. Both can be considered as alternative agents to IV adenosine for FFR measurement. Further clinical validation is warranted.
Vascular damage and reduced tissue perfusion are expected to majorly contribute to the loss of neurons or neural signals around implanted electrodes. However, there are limited methods of controlling the vascular dynamics in tissues surrounding these implants. This work utilizes conducting polymer poly(ethylenedioxythiophene) and sulfonated silica nanoparticle composite (PEDOT/SNP) to load and release a vasodilator, sodium nitroprusside, to controllably dilate the vasculature around carbon fiber electrodes (CFEs) implanted in the mouse cortex. The vasodilator release is triggered via electrical stimulation and the amount of release increases with increasing electrical pulses. The vascular dynamics are monitored in real‐time using two‐photon microscopy, with changes in vessel diameters quantified before, during, and after the release of the vasodilator into the tissues. This work observes significant increases in vessel diameters when the vasodilator is electrically triggered to release, and differential effects of the drug release on vessels of different sizes. In conclusion, the use of nanoparticle reservoirs in conducting polymer‐based drug delivery platforms enables the controlled delivery of vasodilator into the implant environment, effectively altering the local vascular dynamics on demand. With further optimization, this technology could be a powerful tool to improve the neural electrode‐tissue interface and study neurovascular coupling.
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people. Parts two and three continued to review the pharmacological classes of medications that cause or contribute to delirium in older people.
The diatomic molecules, O2, NO and CO, have had a myriad of roles in biology. Due to this, nature has developed many sensing proteins to perceive and respond to changes in the levels of these molecules. The large majority of these proteins are metalloproteins, due to the capacity of metals to bind efficiently to those diatomic molecules. At the same time, nature developed advanced structural and electronic adjustments to fine tune these proteins for sensing, enabling them to function in diverse organisms and environmental conditions. These features are broadly discussed and focus on heme-based proteins, a superfamily of gas sensors. A brief description of heme-based sensors of O2, NO and CO, along with a discussion on their possible role in redox sensing is presented. During the last 20 years, these systems have been more intensively studied. Some key functional and structural features have been revealed and are highlighted here. Beyond the biological sensing systems for these molecules, therapeutic interventions on those gas sensors and other biological targets can also be used. NO and CO donor molecules have become a large area of investigation that has provided compounds for many potential medical treatments, from cardiovascular disorders to bacterial infections, inflammatory issues and cancer therapy. Some newer and exciting strategies to deliver NO and CO, which provide site selectivity, and systems for efficient generation of reactive oxygen species (¹O2) upon light control, are discussed. Overall, we bring together a fundamental understanding of gaseous regulatory metalloproteins and the design of small diatomic molecules as essential components to fuel further these major fields of interconnected studies.
A program was developed in a 400-bed non teaching community hospital to train staff pharmacists in the basic clinical skills required for decentralized pharmaceutical services.
The goals of the program were to enhance the pharmacists' ability to evaluate and monitor drug therapy; to improve drug information retrieval, evaluation, and communication skills; and to develop a working knowledge of pharmacokinetics and pharmacology. Pharmacists were pretested before beginning the program, which included 24 hours of formal instruction on laboratory tests, nutrition, pharmacokinetics, infectious diseases, cardiology, anticoagulation, and bronchodilator therapy. Training manuals containing textbook material and journal articles were provided. Participating pharmacists were evaluated by preceptors and required to score 70% on written examinations. The average pretest and post test scores were 44% and 81%, respectively. All staff pharmacists completed the course, and new pharmacists are now required to pass an examination similar to the posttest.
This training program allowed the pharmacy department to develop and expand its clinical services. Staff pharmacists enhanced basic clinical skills through the program.
Invasive functional evaluation of epicardial coronary stenoses is increasingly utilized in order to target treatment of obstructive coronary artery disease (CAD) to ischemia-producing lesions. Fractional flow reserve (FFR) has been validated against noninvasive stress testing showing high accuracy for the detection of ischemia-producing coronary stenoses, and its use is currently recommended in the guidelines for myocardial revascularization. However, an appropriate understanding of the basic principles and assumptions leading to FFR calculation is necessary in order to guide patient management. In this chapter, we describe the principles, validation process, and practicalities of this technique, with the aim of emphasizing some important aspects to bear in mind when using FFR for the management of patients with CAD during daily clinical practice.
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