Clinical question: For patients chronically treated with loop diuretics, does withholding furosemide on the day of elective noncardiac surgery prevent intraoperative hypotension?
Background: Recent studies have questioned the safety of blood-pressure-lowering medications administered on the day of surgery. Beta-blockers have been associated with an increase in strokes and death perioperatively, and angiotensin receptor blockers (ARB) are frequently withheld on the day of surgery to avoid intraoperative hypotension. The effect of loop diuretics is uncertain.
Study design: Double-blind, randomized, placebo-controlled study.
Setting: Three North American university centers.
Synopsis: One hundred ninety-three patients were instructed to take furosemide or placebo on the day they underwent noncardiac surgery. The primary outcome measure was perioperative hypotension defined as a SBP <90 mmHg for more than five minutes, a 35% drop in the mean arterial blood pressure, or the need for a vasopressor agent. The number of cardiovascular complications (acute heart failure, acute coronary syndrome, arrhythmia, acute cerebrovascular event) and deaths also were analyzed.
Concerns have been raised that loop diuretics might predispose patients to a higher risk of intraoperative hypotension during noncardiac surgery. This trial showed no significant difference in the rates of intraoperative hypotension in patients who were administered furosemide versus those who were not. Although cardiovascular complications occurred more frequently in the furosemide group, the difference was not statistically significant.
Important limitations of the study were recognized. A larger population of patients could have revealed a statistically significant difference in cardiovascular outcomes in the furosemide group. Also, an anesthetic protocol was not utilized, which raises questions about the interaction of furosemide and effect on blood pressure with certain anesthetics.
Bottom line: Administering furosemide prior to surgery in chronic users does not appreciably increase the rate of intraoperative hypotension or cardiovascular events.
Citation: Khan NA, Campbell NR, Frost SD, et al. Risk of intraoperative hypotension with loop diuretics: a randomized controlled trial. Am J Med. 2010;123(11):1059e1-1059e8.
Pediatric HM Literature
Computerized Physician Order Entry Decreases Hospitalwide Mortality
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
Clinical question: What is the effect of computerized physician order entry (CPOE) on hospitalwide mortality?
Background: CPOE has been touted as a key method for improving the quality and safety of patient care. To date, however, studies have not demonstrated definitive benefits, with one study demonstrating an increase in mortality rates in a critical-care unit after CPOE implementation.
Study design: Retrospective cohort study.
Setting: Quaternary-care academic children’s hospital.
Synopsis: More than 97,000 nonobstetric patients admitted to Lucile Packard Children’s Hospital (LCPH) at Stanford University in Palo Alto, Calif., from January 2001 to April 2009 were included in the analysis. The patients were divided into pre- and postintervention groups. The intervention was defined as a “big bang” activation of CPOE on Nov. 4, 2007, affecting 90% of the inpatient beds at LCPH.
After the intervention, mean monthly unadjusted mortality rates decreased to 0.716 deaths from 1.008 per 100 discharges. After adjustment for severity of illness and a rapid-response team (which had previously been shown to decrease mortality rates), mortality rates postintervention continued to remain significantly lower.
This study revealed an impressive reduction in perhaps the ultimate outcome measure: hospitalwide mortality. The authors went to extensive lengths to adjust for potential confounding factors to include delayed implementation of CPOE in the ICUs. As with many complex process improvement efforts, the devil might be in the details of local context and culture. Thus, the software might have been less important than the manner in which the institution adapted to its functionality. Those seeking to replicate these results will need to be mindful of the requisite organizational changes in communication, order standardization, and data retrieval.
Bottom line: CPOE implementation has the potential to significantly reduce hospitalwide mortality rates.
Citation: Longhurst CA, Parast L, Sandborg CI, et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2010;126(1):e1-e8.