Introduction: Clevidipine is a dihydropyridine calcium channel blocker commonly used for acute blood pressure management in the ICU. While generally tolerated, rare cases of hemolysis have been reported, likely secondary to clevidipine’s emulsified lipid carrier causing hypertriglyceridemia, thus destabilizing RBC membranes. This case describes clevidipine associated hemolysis in a patient with mechanical circulatory support.
Description: A 52 year old male with ischemic cardiomyopathy and severely reduced EF underwent HeartMate 3 LVAD placement. He later received a right sided Impella RP for RV failure. After initial resuscitation he developed hypertension and he was kept on high dose clevidipine for MAP control. On hospital day 37, his laboratory data suggested worsening hemolysis, with plasma free hemoglobin >500 mg/dL, LDH >2200 U/L, haptoglobin < 8, and total bilirubin of 1.7 mg/dL. Triglycerides, previously 213 mg/dL, peaked at 1381 mg/dL. Methemoglobinemia (6.9%) and elevated lactate (4.6 mmol/L) were also noted. Clevidipine, lidocaine, and nitric oxide were discontinued on hospital day 37. Following cessation, plasma free hemoglobin fell to 264 by day 38 and to 13 by day 43. LDH normalized to 834, triglycerides fell to 262, and hemolysis labs improved without further intervention. VAD and Impella function remained stable throughout.
Discussion: This case supports a link between clevidipine and intravascular hemolysis, especially amongst patients with LVADs and Impella support who may have lipid sensitive circulations. Clevidipine’s emulsified lipid carrier may cause hypertriglyceridemia and destabilize RBC membranes, thus exacerbating hemolysis already present in mechanically assisted circulation. In our case discontinuation of clevidipine promptly improved hemolysis lab abnormalities. Whether this is a result of actual hemolysis or a laboratory artifact is unknown. This was the first patient in whom we observed the phenomenon, though we have since identified similar findings in additional patients and plan to publish a case series. Clinicians should be cautious with prolonged clevidipine use in patients with mechanical circulatory support, as it may lead to a confusing picture given high risk of hemolysis.
