Caitlin Le, PGY2

Children's Health Children's Medical Center Dallas, DALLAS, Texas

Objectives: 

1. Understand the mechanism of action and potential adverse effect of nicardipine on the developing myocardium.
2. Describe the incidence of adverse effects and the relationship between dosing and efficacy of nicardipine in patients less than 1 year of age.

Abstract:

Introduction

Nicardipine is a dihydropyridine calcium channel blocker that inhibits calcium entry into vascular smooth muscle causing a decrease in vascular resistance and blood pressure. Nicardipine has selectivity for arterial vasodilation, allowing for less inotropic, chronotropic, and dromotropic effects compared to other medications in its class. Its desirable properties and favorable pharmacokinetic profile, including availability of an IV formulation, rapid therapeutic onset, short half-life, and dose-dependent blood pressure reduction allow for easy titration and rapid control of mean arterial pressure, making it a first line option for hypertensive episodes in adult patients.

Management of hypertension in pediatrics is critical. Current options for management of hypertension in this patient population come with potential risks, and may or may not be effective in certain situations. Traditionally, calcium channel blockers were avoided in neonates and infants due to concerns for immature sarcoplasmic reticulum development. This concern has been hypothesized to put this patient population at increased risk of myocardial depression due to lower density of myocardial calcium channels. This underdeveloped physiology is proposed to increase sensitivity to changes in extracellular calcium and calcium channel blockade. Nicardipine blocks calcium influx after depolarization primarily at L-type calcium channels that predominate within vascular smooth muscle cells. This selectivity may limit adverse effects on a potentially underdeveloped myocardium.

Although data regarding nicardipine use in pediatrics is limited, several studies, both prospective and retrospective, have demonstrated safety and efficacy with using nicardipine in this patient population. At Children’s Medical Center Dallas, calcium channel blockers are used in patients less than 1 year of age for hypertension management in the cardiovascular intensive care unit. To the best of our knowledge, there are no published studies assessing nicardipine infusions in infants in the cardiovascular intensive care unit with a substantial sample size. The primary objective of this study is to report adverse events associated with nicardipine use in this patient population. Secondary outcomes will include assessment of dosing and efficacy.

Methods

This is a retrospective electronic chart review that will be conducted on infants admitted to the cardiovascular intensive care unit at Children’s Medical Center Dallas between January 1, 2009 and December 31, 2017. All patients initiated on nicardipine at less than 1 year of age will be included. Patient demographics and clinical will be collected. The primary outcome of this study will assess adverse effects of nicardipine (i.e. clinically relevant episodes of hypotension, dysrhythmias, edema, tachycardia, flushing, diminished cardiac function as evidenced by echocardiogram). Secondary outcomes will evaluate blood pressure changes, nicardipine dosing, and transition to oral anti-hypertensives.

Results

Results will be submitted within final slides.

Conclusion

Conclusion will be submitted within final slides.

Handout Slides:

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