Hypertensive Emergency Management with Clevidipine
If you haven’t used clevidipine for hypertensive emergencies, you may want to give it a try. It comes as a pre-mixed bottle, has a fast onset (2 minutes), you can titrate up at 90 second intervals, and the terminal half-life is 15 minutes! Its onset and half-life are very similar to propofol, so if the BP drops due to other factors (hemorrhage, loss of sympathetic tone, etc) then you can easily titrate it down.
Listen in to learn more about indications, dosing, titration, and potential contra-indications! You can listen by clicking the play button below, or subscribing to GEMCAST on iTunes. If you prefer to read the details, here is an article Leah and I wrote on the topic in EP Monthly.
Take Home Points
For many hypertensive emergencies, clevidipine can be a great first-line option. For hypertension with aortic dissections, still start with a beta-blocker and pain control, as clevidipine can cause a reflex tachycardia.
Start at 1mg/hr, for adults, and you can titrate up every 90seconds by 1mg/hr (ie go from 1mg/hr to 2mg/hr). Usually people end up in around the 6 to 8mg/hr range). Slow down titration as you approach your goal BP, adjusting the dose every 4 minutes rather than every 1.5-2 minutes.
Avoid in patients with egg or soy allergies and use with caution in those with a history of severe or recurrent pancreatitis, as it can cause an acute hypertriglyceridemia.
- Rosenfeldt Z, Conklen K, Jones B, Ferrill D, Deshpande M, Siddiqui FM. Comparison of Nicardipine with Clevidipine in the Management of Hypertension in Acute Cerebrovascular Diseases. J Stroke Cerebrovasc Dis. April 2018.
- Keating GM. Clevidipine: A Review of Its Use for Managing Blood Pressure in Perioperative and Intensive Care Settings. Drugs. 2014;74(16):1947-1960. Aronson S, Dyke CM, Stierer KA, et al. The ECLIPSE Trials: Comparative Studies of Clevidipine to Nitroglycerin, Sodium Nitroprusside, and Nicardipine for Acute Hypertension Treatment in Cardiac Surgery Patients. Anesth Analg. 2008;107(4):1110-1121.
- Watson K, Broscious R, Devabhakthuni S, Noel ZR. Focused Update on Pharmacologic Management of Hypertensive Emergencies. Curr Hypertens Rep. 2017;20(7):56.
- Leixcomp: Clevidipine: Drug information. http://www.uptodate.com. Published 2018. Accessed April 27, 2018.
- Elliott W et al. Drugs used for the treatment of hypertensive emergencies – UpToDate.
- Lexicomp: Clevidipine. UptoDate. http://www.uptodate.com. Accessed June 11, 2018.
- Barrett TW, Schriger DL. Pollack CV, Varon J, Garrison NA, et al. Clevidipine, an Intravenous Dihydropyridine Calcium Channel Blocker, Is Safe and Effective for Treatment of Patients With Acute Severe Hypertension. Ann Emerg Med. 2009;53(3):339-340.
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Dr. Christina Shenvi is an associate professor of Emergency Medicine at the University of North Carolina. She is fellowship-trained in Geriatric Emergency Medicine and is the founder of GEMCast. She is the director of the UNC Office of Academic Excellence, president of the Association of Professional Women in Medical Sciences, co-directs the ACEP/CORD Teaching Fellowship, is on the Annals of EM editorial board, is on the Geriatric ED Accreditation board of governors, and she teaches and writes about time management at timeforyourlife.org.