Letter to the Director
Management of hypertensive crisis with clevidipine in the perioperative setting of a critically ill patient, non-responder to high doses of nitroglycerin, labelatol, urapidil, doxazosin and furosemide
Tratamiento de una crisis hipertensiva con clevidipino en una en paciente crítica no respondedora a dosis altas de nitroglicerina, labetalol, urapidilo, doxazosina y furosemida
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López Pérez, M.Y. Tebar Cuesta, J.L. Mesa Ruiz, J.J. Arcas Bellas" "autores" => array:4 [ 0 => array:4 [ "nombre" => "V." "apellidos" => "López Pérez" "email" => array:1 [ 0 => "Ver_nica@icloud.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.Y." "apellidos" => "Tebar Cuesta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.L." "apellidos" => "Mesa Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.J." "apellidos" => "Arcas Bellas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de una crisis hipertensiva con clevidipino en una en paciente crítica no respondedora a dosis altas de nitroglicerina, labetalol, urapidilo, doxazosina y furosemida" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Labile hypertension is common in patients admitted to resuscitation/intensive care units. Hypertensive crises (SAP > 180 mmHg or DAT > 110 mmHg) can be difficult to control, especially in elderly patients, and increases the risk of morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a critically ill ASA IV patient admitted to our unit who presented a hypertensive crisis that did not respond to solinitrin, labetalol, urapidil or doxazosin, but did respond to minimal doses of clevidipine.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 78-year-old woman (89 kg, 155 m, BMI: 37.04), with a personal history of hypertension (HT) in treatment with 4 mg/12 h doxazosin. She remained in our unit after surgery for endometrial cancer with multiple intestinal resections. Postoperative evolution was poor, with anastomotic leak at 3 days that required reoperation. She also developed cardiac (atrial fibrillation with rapid ventricular response), respiratory (acute respiratory distress syndrome [ARDS]), urological (bladder fistula), and neurological (critical illness polyneuropathy and disorientation) complications together with altered liver parameters. She initially required vasoactive support with norepinephrine, but shortly after presented uncontrollably high blood pressure, despite having started 4 mg/12 h oral doxazosin and 10 mg/8 h IV furosemide some days prior. We initially started perfusion of up to 4 μg/min nitro-glycerine; labetalol was later was added and up-dosed to 20 mg/h, together with repeated boluses of 10 mg, 15 mg and 25 mg urapidil every 5 min. Despite this, blood pressure remained high. However, the patient showed excellent response to minimal doses of clevidipine (4 ml/h, 2 mg/h), allowing us to reduce infusion of nitro-glycerine and labetalol after a few minutes and withdraw them completely after 90 min. She remained on 4 ml/h clevidipine perfusion for approximately 1 day, with mean arterial pressure of around 75 mmHg. Clevidipine was halved at 24 h, and suspended at 36 h, after which blood pressure was adequately controlled with 4 mg/12 h oral doxazosin.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Hypertensive crises are common in resuscitation/intensive care units and can have important consequences on different organs. The mechanisms behind postoperative HT include increased systemic vascular resistance, hyperadrenergic response to surgery,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> changes in intravascular preload and volume, activation of the renin-angiotensin system, and increased serotonin.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The most common causes include central nervous system (pain, anxiety, delirium), renal (kidney failure, hypervolaemia), respiratory (hypoxemia and hypercapnia), and metabolic (hypoglycaemia, corticosteroids, pheochromocytoma, substance abuse, etc.) disorders, or the discontinuation of the patient’s usual medication. Our patient remained sedated, pain was controlled with morphine and midazolam, she was properly ventilated and oxygenated through controlled ventilation, labs were normal, and she had been treated with doxazosin and furosemide for several days, maintaining acceptable urine output.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The most widely used of the many different therapeutic options for severe HT in resuscitation units is nitro-glycerine, a venous vasodilator that can cause reflex tachycardia. It is indicated in HT associated with volume overload and pulmonary oedema1, and when there is a risk of ischaemic heart damage. Labetalol is a α<span class="elsevierStyleInf">1</span>, β<span class="elsevierStyleInf">1</span> and β<span class="elsevierStyleInf">2</span> blocker with negative ionotropic and chronotropic effects. It can be used together with nitro-glycerine to control heart rate. Alternatives include sodium nitroprusside, a potent arterial and venous vasodilator that can accumulate toxic metabolites, urapidil (a peripheral α blocker) commonly used in isolated boluses, and doxazosin (an α<span class="elsevierStyleInf">1</span>-adrenergic receptor blocker). Centrally acting diuretics or antihypertensives, such as clonidine and dexmedetomidine, which have negative ionotropic and chronotropic effects, can also be used, particularly in patients with pain, anxiety or withdrawal syndromes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Clevidipine is a dihydropyridine calcium channel blocker with arterial-selective vasodilator action that does not affect vascular capacitance.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It works by inhibiting the flow of calcium into the vascular smooth muscle,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> has a fast onset, is easily titratable with a predictable dose response, has an ultrashort half-life, and no rebound effect after withdrawal. It is metabolized by plasma esterases and has few drug interactions, making it particularly useful in patients with kidney, liver and heart failure (because it lacks negative chronotropic effects<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>). Multiple studies (ECLIPSE<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a>, EXHAUST 1 and 2<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and VELOCITY<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>) have demonstrated the efficacy and safety of clevidipine in the perioperative period. Its use is contraindicated in patients with allergy to soy or eggs, and in those with lipid metabolism deficiencies. Adverse effects are rare, but acute kidney failure, myocardial infarction, atrial fibrillation, fever, nausea, oedema, or insomnia have been reported.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This case report is limited by the lack of invasive blood pressure (BP) monitoring, due to the impossibility of arterial cannulation. Some non-invasive monitors give continuous control of BP and monitor haemodynamic variables (cardiac output, stroke volume, variation in stroke volume). These device would have been suitable in high-risk patients with arterial cannulation difficulties, such as our case.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, in this case clevidipine gave effective, rapid control of BP in a patient who did not respond to 5 drugs. Blood pressure levels remaining stable after withdrawal of clevidipine. Its suitability in patients with liver, kidney, and heart failure, its ultra-short half-life, its easy titration, and its predictable effect make it a good option in high-risk postoperative patients in resuscitation units. However, no single drug is ideal in all situations - there are only some that are safer in certain cases. Differential diagnosis of the pathophysiological cause can help resuscitation units decide between existing therapeutic options.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have not received funding for this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López Pérez V, Tebar Cuesta MY, Mesa Ruiz JL, Arcas Bellas JJ. Tratamiento de una crisis hipertensiva con clevidipino en una en paciente crítica no respondedora a dosis altas de nitroglicerina, labetalol, urapidilo, doxazosina y furosemida. Rev Esp Anestesiol Reanim. 2021;68:239–240.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Control of hypertension in the critically ill: a pathophysiological approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.R. Salgado" 1 => "E. Silva" 2 => "J.L. 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