To the Editor
CRNA Duerr-Trebilcock points out that all that is white is not necessarily propofol (APSF Newsletter, Fall 2011). The pretender in question is the surgical lubricant Rotaglide®. However, a much more potentially dangerous pretender is clevidipine (Cleviprex®). Since clevidipine, a calcium channel antihypertensive, is, like propofol, formulated in a lipid emulsion, it too appears milky white (Figure 1). Since it is a potent antihypertensive, clevidipine is much more likely to be in a hospital formulary and perhaps find its way into the operating room or other procedural areas. This potential danger was initially brought to the attention of Veteran Affairs Hospitals by the VA National Pharmacy Benefits Management Services (PBM) in 2009. I believe the medical profession in general should be made aware of this as well.
Bruce Kleinman, MD
Hines VA Hospital
Hines, IL 60141A
Department of Veterans Affairs Veteran Health Administration (VHA)
Pharmacy Benefits Management Services (PBM) & Medical Advisory Panel (MAP)
VA Center for Medication Safety (VAMedSAFE)
NATIONAL PBM COMMUNICATION · April 30, 2009
Propofol (Diprivan®) and Clevidipine (Cleviprex®) and Potential Look-Alike Concern
- Propofol (Diprivan®) is an intravenous (IV) sedative agent used in the induction and maintenance of general anesthesia, monitored anesthesia care sedation, procedural sedation, and sedation for mechanical ventilation (See Figure 1).
- Clevidipine (Cleviprex®) is an IV calcium-channel blocker used to treat peri-operative hypertension as well as acute, severe hypertension (See Figure 1).
- Both are milky white solutions that are infused intravenously.
- Both are available in small glass bottles and used in the intensive care unit (ICU)/operating room (OR)/emergency department (ED) settings.
- Due to the above similarities, a concern of potential “look-alike” confusion between the 2 products has been raised.
- Patients may be at risk for suffering significant harm due to the acute situation(s) in which the patient would be receiving these medications.– Unsuccessful sedation resulting in rapid awakening, as well as anxiety, agitation, and resistance to mechanical ventilation could result if a patient did not receive their intended dose of propofol. If a patient receives propofol instead of clevidipine without a protected airway, the patient could suffer from respiratory depression or arrest.
– Uncontrolled blood pressure could result if a patient did not receive their intended dose of clevidipine. If a patient receives clevidipine instead of propofol without an elevated blood pressure, hypotension could result.
- Staff must be informed of potential look-alike confusion between Propofol and Clevidipine (Cleviprex®).
- Pharmacy must store Propofol (Diprivan®) and Clevidipine (Cleviprex®) in separate areas in the pharmacy. [Clevidipine (Cleviprex®) vials should be refrigerated at 2-8°C (36-46°F). Vials in cartons may be stored at temperatures up to 25°C (77°F) for no greater than 2 months.1 Propofol (Diprivan®) should be stored between 4-22°C (40-72°F).2]
- Pharmacy must create a warning system for staff to notify of potential look-alike confusion between Propofol and Clevidipine (Cleviprex®) (e.g., computer alerts during the ordering/verifying process and/or warning stickers on packaging).
- Drug/syringe used must be verified with the name of the drug on the prescription.
- Cleviprex package insert. Parsippany, NJ: The Medicines Company; 2008 Aug.
- Diprivan package insert. Wilmington, DE: AstraZeneca; 2005 Aug.
Facility COS: Forward this document to all appropriate providers who prescribe/use/handle this agent (e.g., providers, nurses and technicians who work in the ICU/OR/ED settings, including contract providers, etc.). In addition, forward to the Associate Chief of Staff (ACOS) for Research and Development (R&D). Forward to other VA employees as deemed appropriate. Report completion of actions to the Facility Director.
ACOS for R&D: Forward this document to Principal Investigators (PIs) who have authority to practice at the facility and to your respective Institutional Review Board (IRB).