Isn't that Propofol…why isn’t the patient intubated??!!”
Yes, that is actually a question I have received numerous times while infusing Clevidipine, a calcium channel blocker used to treat hypertension.
Clevidipine (Cleviprex) has been around for about a decade (FDA Approved 2008) but is now just starting to gain wide popularity. It's milk like appearance demands curiosity from even experienced healthcare providers who immediately think of the widely popular anesthetic propofol.
Propofol and Clevidipine (and in some circumstances medications like etomidate, diazepam, amphotericin B, dexamethasone, and certain vitamins A, D2, E, K1) achieve their characteristic milky appearance not due to the medications themselves, but from the lipid emulsion preparation that is added as use as a vehicle.
Lipid emulsions tend to be made up of varying percentages of soy bean oil, egg phospholipids and glycerin. The purpose of formulating a drug as a lipid emulsion varies drug to drug but can serve to reduce injection site pain, irritation and phlebitis, increase drug metabolism by certain organs, decrease nephrotoxicity, increase potency, and perhaps most importantly, create further drug stability, especially in those that are lipophilic, like Propofol.
Clevidipine is used commonly in the OR, ICU and in the ED for severe hypertension. It is unique in that it is highly vasoselective, specifically affecting arterial dilation and having little to no effect on cardiac or smooth muscle (thus no effect on cardiac conduction or contractility).This in turn results in a decrease in systemic vascular resistance (SVR) while maintaining cardiac preload.
Its dosing is not weight dependent and the half-life is just short of one minute, leading to an onset and duration that is extremely rapid and simple to titrate. This is what makes it popular for treatment of intra-operative hypertension.
Clevidipine comes in a concentration of 0.5mg/ml and is recommended to be initiated at 1-2mg/hr (2-4ml/hr). The dose can be doubled every 90 seconds until the blood pressure goal is met. For example, if the patient is receiving 4mg/hr but is still hypertensive, the dose would be increased to 8mg/hr (4ml/hr).
Just like propofol, and any other lipid-based medication, allergies for soybeans, soy products, eggs, or egg products should be considered. Also, microbial growth can occur quickly in so aseptic technique must be used and the tubing/remaining drug changed every 12 hours.
Overall Clevidpine is proving to be a great medication with a safety profile similar to that of nitroglycerin, nitroprusside and nicardipine.
As of 2018 it is now apart of the American Heart Association Stroke Guidelines in treatment of arterial hypertension Acute Ischemic Stroke (AIS), so prepare to see an uptick in its use within your hospital setting.
Cleviprex package insert. Parsippany, NJ: The Medicines Company; 2008 Aug.
M Buys, PA Scheepers & AI Levin (2015) Lipid emulsion therapy: non-nutritive uses of lipid emulsions in anaesthesia and intensive care, Southern African Journal of Anaesthesia and Analgesia, 21:5, 124-130, DOI: 10.1080/22201181.2015.1095470