Comparison of Clevidipine and Nicardipine for Acute Blood Pressure Reduction in Hemorrhagic Stroke.

BACKGROUND: Intracranial hemorrhage is associated with high mortality and morbidity. Lowering systolic blood pressure (SBP) with an intravenous antihypertensive, such as nicardipine or clevidipine, may reduce the risk of hematoma expansion and rebleeding. Previous studies comparing nicardipine and clevidipine in patients with stroke found no significant difference in blood pressure management. The inclusion of patients with ischemic stroke limited those studies because of convoluted results related to faster door-to-needle times. The purpose of this study was to compare clevidipine with nicardipine in time to goal SBP in hemorrhagic stroke. METHODS: This single-center retrospective observational cohort study evaluated adult hemorrhagic patients with stroke who received clevidipine or nicardipine from January 1, 2015, to December 31, 2020. Patients were excluded if they had trauma-related hemorrhage, received concurrent continuous intravenous antihypertensives, received the study drug for less than 1-h duration, had a less than 24-h washout period between agents, required any dialysis, were pregnant, or were incarcerated. The primary outcome was time to goal SBP. Secondary outcomes included need for additional antihypertensives, percentage of time at goal SBP, all-cause mortality, 30-day readmission, rebleeding, total volume of antihypertensive infusion, hematoma expansion, intensive care unit length of stay (LOS), hospital LOS, and cost of infusion. Safety outcomes included hypotension, severe hypotension, rebound hypertension, bradycardia, tachycardia, onset of atrial fibrillation, and acute kidney injury. RESULTS: Of 89 patients included in this study, 60 received nicardipine and 29 received clevidipine. There was no significant difference between nicardipine and clevidipine in time to goal SBP in the unmatched cohort (30 vs. 45 min; p = 0.73) or the propensity-score-matched cohort (30 vs. 45 min; p = 0.47). Results were not affected by potential confounders in the multiple linear regression. The nicardipine group had a higher total volume from infusion compared with the clevidipine group (1410 vs. 330 mL; p < 0.0001) but significantly lower cost ($99.6 vs. $497.4; p < 0.0001). There were no significant differences in need for additional antihypertensives, percentage of time at goal SBP, all-cause mortality, 30-day readmission, rebleeding, hematoma expansion, intensive care unit LOS, and hospital LOS. Compared with the clevidipine group, the nicardipine group had less rebound hypertension (40% vs. 75.9%; p = 0.0017) and less bradycardia (23.3% vs. 44.8%; p = 0.05). There were no significant differences in hypotension, severe hypotension, tachycardia, and acute kidney injury. CONCLUSIONS: In patients with hemorrhagic stroke, nicardipine appeared to have similar efficacy as clevidipine in SBP reduction, with a more likely reduction of rebound hypertension and drug cost. This retrospective study was underpowered, which may limit these implications. Further prospective studies are warranted to confirm these results.

Failure of chemical thromboprophylaxis in critically ill medical and surgical patients with sepsis.

PURPOSE: Critically ill patients who develop sepsis may be at a higher risk of venous thromboembolism (VTE) prophylaxis failure; however, studies in this population are limited. The objective of this study was to identify the incidence of VTE prophylaxis failure in this population. METHODS: This retrospective review of patients admitted to the intensive care unit between February 2013 and September 2015 included patients who were diagnosed with sepsis and received heparin or enoxaparin VTE prophylaxis. RESULTS: Of the 355 patients included, 42 (12.5%) developed a VTE. Acute respiratory distress syndrome (ARDS) (31% vs 16.7%, P = .0272) and higher positive end expiratory pressure (10 vs 8, P = .0066) were associated with increased risk of VTE prophylaxis failure. Logistic regression identified ARDS an event risk factor (odds ratio, 2.58; 95% confidence interval, 1.22-5.42). The VTE was associated with an increased intensive care unit (14 vs 9 days, P = .01) and hospital length of stay (26 vs 15 days, P < .0001). The median time from sepsis diagnosis to VTE event was 9 days (interquartile range, 5-13). CONCLUSION: Critically ill patients with sepsis had a high rate of VTE prophylaxis failure with ARDS being identified as a risk factor for VTE prophylaxis failure.