PHENYLEPHRINE HYDROCHLORIDE

(fen-ill-ef'rin) AK-Dilate Ophthalmic, Alconefrin, IsoptoFrin, Mydfrin, Neo-Synephrine, Nostril, Rhinall, Sinarest Nasal, Sinex Classifications:EYE AND NOSE PREPARATION; ALPHA-ADRENERGIC AGONIST; MYDRIATIC; DECONGESTANT;
THERAPEUTIC: DECONGESTANT; MYDRIATIC; VASOCONSTRICTOR

Prototype: Methoxamine Pregnancy Category: C

Availability
10 mg chewable tablet; 0.125%, 0.16%, 0.5%, 1% nasal solution; 0.12%, 2.5%, 10% ophthalmic solution; 10 mg/mL injection

Action
Potent, synthetic, direct-acting sympathomimetic with strong alpha-adrenergic and weak beta-adrenergic cardiac stimulant actions.Produces little or no CNS stimulation.Elevates systolic and diastolic pressures through arteriolar constriction.Reduces intraocular pressure by increasing outflow and decreasing rate of aqueous humor secretion.

Therapeutic Effect
Topical applications to eye produce vasoconstriction and prompt mydriasis of short duration, usually without causing cycloplegia. Nasal decongestant action qualitatively similar to that of epinephrine but more potent and has longer duration of action.

Uses
Parenterally to maintain BP during anesthesia, to treat vascular failure in shock, and to overcome paroxysmal supraventricular tachycardia. Used topically for rhinitis of common cold, allergic rhinitis, and sinusitis; in selected patients with wide-angle glaucoma; as mydriatic for ophthalmoscopic examination or surgery, and for relief of uveitis.

Contraindications
Severe coronary disease, severe hypertension, atrial fibrillation, atrial flutter, cardiac arrhythmias; cardiac disease, cardiomyopathy; uncontrolled hypertension; ventricular fibrillation or tachycardia; acute MI, angina; cerebral arteriosclerosis, MAOI; narrow-angle glaucoma (ophthalmic preparations); labor, delivery; pregnancy (category C).

Cautious Use
Hyperthyroidism; diabetes mellitus; older adult patients; 21 d before or following termination of MAO inhibitor therapy; lactation.Ophthalmic solution (10%): Cardiovascular disease; diabetes mellitus; hypertension; aneurysms; infants.

Route & Dosage

Hypotension

Adult:IM/SC 110 mg (initial dose not to exceed 5 mg) q1015min as needed IV 0.10.18 mg/min until BP stabilizes; then 0.040.06 mg/min for maintenance

Ophthalmoscopy

See Appendix A
Supraventricular Tachycardia

Adult:IV 0.250.5 mg bolus, then 0.10.2 mg doses (total max: 1 mg)

Vasoconstrictor

Adult:Ophthalmic See Appendix A1 Intranasal Small amount of nasal jelly placed into each nostril q34h as needed or 23 drops or sprays of 0.250.5% solution q34h as needed Child:Intranasal<6 y, 23 drops or sprays of 0.125% solution q34h as needed; 612 y, 23 drops or sprays of 0.25% solution q34h as needed

Administration
Instillation
y y

y y

Nasal preparations: Instruct patient to blow nose gently (with both nostrils open) to clear nasal passages before administration of medication. Instillation (drops): Tilt head back while sitting or standing up, or lie on bed and hang head over side. Stay in position a few minutes to permit medication to spread through nose. (Spray): With head upright, squeeze bottle quickly and firmly to produce 1 or 2 sprays into each nostril; wait 35 min, blow nose, and repeat dose. (Jelly): Place in each nostril and sniff it well back into nose. Clean tips and droppers of nasal solution dispensers with hot water after use to prevent contamination of solution. Droppers of ophthalmic solution bottles should not touch any surface including the eye. Ophthalmic preparations: To avoid excessive systemic absorption, apply pressure to lacrimal sac during and for 12 min after instillation of drops.

Subcutaneous/Intramuscular
y

Give undiluted.

Intravenous
y

Note: Ensure patency of IV site prior to administration.

PREPARE:Direct: Dilute each 1 mg in 9 mL of sterile water. IV Infusion: Dilute each 10 mg in 500 mL D5W or NS

(concentration: 0.02 mg/mL).

ADMINISTER:Direct: Give a single dose over 60 sec. IV Infusion: Titrate to maintain BP. INCOMPATIBILITIESSolution/additive:PhenytoinY-site:Propofol, thiopental.
y

Protect from exposure to air, strong light, or heat, any of which can cause solutions to change color to brown, form a precipitate, and lose potency.

Adverse Effects ( 1%)

Special Senses:Transient stinging, lacrimation, brow ache, headache, blurred vision, allergy (pigmentary deposits

on lids, conjunctiva, and cornea with prolonged use), increased sensitivity to light. Rebound nasal congestion (hyperemia and edema of mucosa), nasal burning, stinging, dryness, sneezing.CV: Palpitation, tachycardia, bradycardia (overdosage), extrasystoles, hypertension. Body as a Whole: Trembling, sweating, pallor, sense of fullness in head, tingling of extremities, sleeplessness, dizziness, light-headedness, weakness, restlessness, anxiety, precordial pain, tremor,severe visceral or peripheral vasoconstriction, necrosis if IV infiltrates.

Interactions
Drug:ERGOT ALKALOIDS, guanethidine,reserpine,TRICYCLIC ANTIDEPRESSANTS increase pressor effects of

phenylephrine; halothane,digoxin increase risk of arrhythmias; MAO INHIBITORS cause hypertensive crisis; oxytocin causes persistent hypertension; ALPHA BLOCKERS, BETA BLOCKERS antagonize effects of phenylephrine.

Pharmacokinetics
Onset: Immediate IV; 1015 min IM/SC. Duration: 1520 min IV; 30120 min IM/SC; 36 h topical. Metabolism:

In liver and tissues by monoamine oxidase.

Nursing Implications
Assessment & Drug Effects
y

y y y

Monitor infusion site closely as extravasation may cause tissue necrosis and gangrene. If extravasation does occur, area should be immediately injected with 510 mg of phentolamine (Regitine) diluted in 1015 mL of NS. Monitor pulse, BP, and central venous pressure (q25min) during IV administration. Control flow rate and dosage to prevent excessive dosage. IV overdoses can induce ventricular dysrhythmias. Observe for congestion or rebound miosis after topical administration to eye.

Patient & Family Education

y y y y y

Be aware that instillation of 2.510% strength ophthalmic solution can cause burning and stinging. Do not exceed recommended dosage regardless of formulation. Inform the physician if no relief is experienced from preparation in 5 d. Be aware that systemic absorption from nasal and conjunctival membranes can occur, though infrequently (see ADVERSE EFFECTS). Discontinue drug and report to the physician if adverse effects occur. Wear sunglasses in bright light because after instillation of ophthalmic drops, pupils will be large and eyes may be more sensitive to light than usual. Stop medication and notify physician if sensitivity persists beyond 12 h after drug has been discontinued. Be aware that some ophthalmic solutions may stain contact lenses.

Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; name; Prototype drug

Canadian drug

NITROPRUSSIDE SODIUM
(nye-troe-pruss'ide) Nitropress Classifications:NONNITRATE VASODILATOR; ANTIHYPERTENSIVE; THERAPEUTIC: ANTIHYPERTENSIVE;
NONNITRATE VASODILATOR

Prototype: Hydralazine Pregnancy Category: C

Availability
50 mg injection

Action
Potent, rapid-acting hypotensive agent with effects similar to those of nitrates. Acts directly on vascular smooth muscle to produce peripheral vasodilation, with consequently marked lowering of arterial BP that is associated with slight increase in heart rate, mild decrease in cardiac output, and moderate lowering of peripheral vascular resistance.

Therapeutic Effect
Effective antihypertensive agent used for rapid reduction of high blood pressure.

Uses
Short-term, rapid reduction of BP in hypertensive crises and for producing controlled hypotension during anesthesia to reduce bleeding.

Unlabeled Uses
Refractory CHF or acute MI.

Contraindications
Compensatory hypertension, as in atriovenous shunt or coarctation of aorta, and for control of hypotension in patients with inadequate cerebral circulation; pregnancy (category C), lactation.

Cautious Use
Hepatic insufficiency, hypothyroidism, severe renal impairment, hyponatremia, older adult patients with low vitamin B12 plasma levels or with Leber's optic atrophy.

Route & Dosage

Hypertensive Crisis

Adult:IV 0.30.5 mcg/kg/min (average 3 mcg/kg/min) Child:IV 1 mcg/kg/min (average 3 mcg/kg/min) (max 5 mcg/kg/min)

Administration

Intravenous
PREPARE:Continuous: Dissolve each 50 mg in 23 mL of D5W. Further dilute in 250 mL D5W to yield 200 mcg/mL

or 500 mL D5W to yield 100 mcg/mL. Lower concentrations may be desirable depending on patient weight. Following reconstitution, solutions usually have faint brownish tint; if solution is highly colored, do not use it. Promptly wrap container with aluminum foil or other opaque material to protect drug from light.
ADMINISTER:Continuous: Administer by infusion pump or similar device that will allow precise measurement of

flow rate required to lower BP. Give at the rate required to lower BP, usually between 0.510 mcg/kg/min. DO NOT exceed the maximum dose of 10 mcg/kg/min nor give this dose for longer than 10 min.
INCOMPATIBILITIESSolution/additive:Amiodarone,propafenone.Y-site:Cisatracurium,haloperidol, levofloxacin.
y

Store reconstituted solutions and IV solution at 1530 C (5986 F) protected from light; stable for 24 h.

Adverse Effects ( 1%)

Body as a Whole: Diaphoresis, apprehension, restlessness, muscle twitching, retrosternal discomfort. Thiocyanate

toxicity (profound hypotension, tinnitus, blurred vision, fatigue, metabolic acidosis, pink skin color, absence of reflexes, faint heart sounds, loss of consciousness). CV: Profound hypotension, palpitation, increase or transient lowering of pulse rate, bradycardia, tachycardia, ECG changes. GI: Nausea, retching, abdominal pain. Metabolic: Increase in serum creatinine, fall or rise in total plasma cobalamins. CNS: Headache, dizziness. Special Senses: Nasal stuffiness. Other: Irritation at infusion site.

Interactions
No clinically significant interactions established.

Pharmacokinetics
Onset: Within 2 min. Duration: 110 min after infusion is terminated. Metabolism: Rapidly converted to cyanogen in erythrocytes and tissue, which is metabolized to thiocyanate in liver. Elimination: Excreted in urine primarily as thiocyanate. Half-Life: (thiocyanate): 2.77 d.

Nursing Implications
Assessment & Drug Effects
y y y y y

Monitor constantly to titrate IV infusion rate to BP response. Relieve adverse effects by slowing IV rate or by stopping drug; minimize them by keeping patient supine. Notify physician immediately if BP begins to rise after drug infusion rate is decreased or infusion is discontinued. Monitor I&O. Lab tests: Monitor blood thiocyanate level in patients receiving prolonged treatment or in patients with severe kidney dysfunction (levels usually are not allowed to exceed 10 mg/dL). Determine plasma cyanogen level following 1 or 2 d of therapy in patients with impaired liver function.

Common adverse effects in italic, life-threatening effects underlined; generic names in bold; classifications in SMALL CAPS; name; Prototype drug\

Canadian drug