Nicole Kupchik

Author, Independent Clinical Nurse Specialist & Educator

Critical Care Consulting | Quality Improvement/Program Development | Critical Care Education | Certification Reviews

Smith Brothers Farms - Reduced Fat MilkMost of us, as kids, were taught that milk was good for us. Milk gave us calcium to build strong bones. However, too much or too little calcium in our system can create other problems.

In 2014, British Medical Journal published a study that although milk may prevent fractures, it possible contributes to early mortality. Possibly it was related to D-galactose which breaks down lactose causing an oxidative stress (1).

In our bodies, our vascular system also uses Calcium to regulate the influx of ions within the cell wall. This is important to our vascular tone and overall cardiac function. The calcium channel can be used to treat hypertension and help with rate controlling certain arrhythmias.

 

Hypertension Treatment Options:

[E/I = Emergent and/or Inpatient] [OP = Outpatient/home]

  • Hydrazinophthalazine (aka Hydralazine) [E/I or OP]
  • beta blockers (No longer first line option) [E/I or OP]
  • angiotensin receptor blockers [Primarily OP]
  • angiotensin converting enzyme inhibitor [Primarily OP]
  • calcium channel blockers [E/I or OP]
  • renin inhibitors [Primarily OP and have some intermittent FDA issues]
  • nitrates [E/I or OP]
  • diuretic therapy [E/I or OP]

Each therapy has positives and negatives for the treatment of hypertension. Some limitations to hypertensions medications are allergy/sensitivity to the medication, too much or too little effectiveness, cost, age, and renal function.

 

Calcium Channel Blockers:

For a quick review on Calcium Channel Blockers, here is a great video from MoMetrix: https://youtu.be/t-vqTO5bPKU

Calcium Channel Blocker Chart

 

Clevidipine (AKA – Cleviprex)

This Calcium Channel Blocker was released in 2008. Unlike most CCBs, Cleviprex is able to reduce systemic vascular resistance (SVR) without reducing preload (3). This became especially important in the cardiac surgery population.

Clinical usage of the medication include the management of pre and post-operative hypertension in the critical care & operative settings and the management of severe hypertension (aka Hypertensive Emergency, no longer called “Hypertensive Crisis”).

Now that I have read this far, what does milk have to do with any of this? Well, Cleviprex is a lipid/milky substance and uses the calcium channel. That’s about it.

 

Initial Studies of the effectiveness of Clevidipine:

  1. ESCAPE 1 (Preoperative)
  2. ESCAPE 2 (Post-operative)
  3. ECLIPSE (Combined retro data analysis)
  4. Velocity (Severe Hypertension Study)

Results were found to be similar to other antihypertensive: sodium nitroprusside, nitroglycerin, and nicardipine (4). Of note, it was interesting that dosing in ESCAPE trials was in micrograms/kilogram/minute and Velocity study was expressed in milligrams/hour.

 

Were there side effects during the study?

Many of the results were the same as other drugs in the cardiac surgery population: Atrial Fibrillation, Cardiac Arrest, and Myocardial Infarction. There is potential risk for rebound/reflexive tachycardia related to hypotension.

 

Dosing & Administration:

The manufacturer recommends 1 – 2 mg/hr hour. Nurses can double dose up to every 90 seconds until goal blood pressure is reached. 1 – 2 mg/hr dose changes equals about 2 – 4 mmHg systolic pressure change (5). This means the drug has a very high action potential and a short half life.

Hypothetical Example: Patient Systolic 220/100 mm Hg start at 2 mg/hr at 01:09. By 01:11, BP now 216/99 mm Hg.

At this point the RN, would then increase again to 3 – 4 mg/hr total. In 90 seconds, the next BP should be 212 systolic or less.

Again in 90 seconds, the RN would titrate up and the dose would be 5 – 6 mg/hr total resulting in a BP of 208 systolic or less.

By the 6 minute mark, the RN would be at a dose 7 – 8 mg/hr with a BP around 200 Systolic or less pending the patient’s intrinsic reaction to the medication.

 

Max Dosing:

The data is a bit fuzzy here as some studies were up to 32 mg/hr in the severe hypertension realm. However, the manufacturer recommends only up to 21 mg/hr. This maximum dosing is related to the high lipid load this medication delivers.

 

So why wouldn’t I choose this over other medications if it doesn’t affect preload and has the same results?

  • Cost
  • Potential patient allergy: soy or egg
  • Hyperlipidemia
  • Aortic Stenosis (** the reduction in afterload = reduction in myocardial oxygen delivery)

 

What do I have to watch out for when I administer this drug?

  • Mixing the medication, use sterile technique because of the lipid base it is more prone to bacterial and viral load **Bottles are only viable for 12 hours once spiked**
  • Hypotension. If this occurs, slowly wean the infusion back down (about 1 – 2 mg every 90 second to 5 minutes) until goal pressure is reached
  • Reflex tachycardia. NOTE: This could be a sign your patient is hypovolemic. If a patient vasodilates too quickly, the heart will increase its rate to combat the loss of cardiac output
  • Allergic reaction. Treat as you would any other medication allergy, but ensure its not related to soy or egg.
  • Cardiac Monitoring – Both ECG and Blood Pressure are prescribed for administration of this medication.

 

Summary

Calcium channel blockers provide one method for treating hypertension both in the cardiac surgery and patients with severe hypertension. Choosing one that best fits the patient can be challenging. As nurses, we need to understand the risks and benefits of using a calcium channel blocker versus other methods. Cleviprex will continue to be an option for patients as the drug becomes more widely used.

 

References:

  1. BMJ. (2014) Milk intake and the risk of mortality and fractures in wormen. Retrieved January 3, 2018 from http://www.bmj.com/content/349/bmj.g6015
  2. Calcium Channel Blocker Image. Retrieved January 3, 2018 from: https://www.pinterest.com/explore/calcium-channel-blocker/
  3. Cleviprex(R) intravenous injection, clevidipine intravenous injection. The Medicines Company (per DailyMed), Parsippany, NJ, 2011
  4. ESCAPE & ECLIPSE trials summary. Retrieved January 3, 2018 from http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0ahUKEwia9KfXp7vYAhVprVQKHeLtA_0QFgg4MAI&url=http%3A%2F%2Fclintrialresults.org%2FSlides%2FClevidipine%2520Clinical%2520Trials%2520Review%2520081408.ppt&usg=AOvVaw1SV1pvYfNhBbds72Gjgtu_
  5. Cleviprex(R) intravenous injection, clevidipine intravenous injection. The Medicines Company (per DailyMed), Parsippany, NJ, 2013

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