Implementation of a diuretic stewardship program in a pediatric cardiovascular intensive care unit to reduce medication expenditures

Use of Furosemide and Chlorothiazide Combination Continuous Infusion in Furosemide-Refractory Patients in the Pediatric Intensive Care Unit: A Retrospective Cohort Study

OBJECTIVE

Our objective was to describe the efficacy and safety of furosemide and chlorothiazide combination continuous infusion (FCCCI) in children in a pediatric intensive care unit (ICU), including postoperative cardiac patients.

METHODS

This was a retrospective cohort study in a pediatric ICU within a tertiary care teaching hospital. Children aged < 18 years admitted from 1 January 2010 to 31 December 2019 were included if they received a furosemide infusion for at least 6 h and then transitioned to FCCCI. Each patient acted as their own control.

RESULTS

A total of 203 patients (107 [53%] postoperative cardiac) met the study inclusion criteria. The study population was 55% male and 74% Caucasian, with a median age of 4.9 months. Of the total patients, 143 (70.4%) required mechanical ventilation and 39 (19.2%) required dialysis. The median duration of furosemide and FCCCI was 24.6 h (interquartile range [IQR] 12.4-54) and 41 h (IQR 15-162), respectively. Urine output increased by 52% with FCCCI (mean increase of 2.2 mL/kg/h [95% confidence interval {CI} 1.8-2.5]; p < 0.01). The change to FCCCI led to a net negative daily fluid balance (mean difference - 301.9 mL/day [95% CI - 390.9 to - 212.9]; p < 0.01). FCCCI resulted in a greater requirement for potassium bolus supplementation (mean increase of 12.8 boluses [95% CI 8.5-17.2]; p < 0.01) and a small but statistically significant increase in serum creatinine (mean difference 0.1 mg/dL [95% CI 0.06-0.14]; p < 0.01) with a resultant decrease in estimated glomerular filtration rate (mean difference - 13.5 [95% CI 9.7-17.4]; p < 0.01). Of the furosemide-refractory patients, 78.9% were responsive to FCCCI. Younger patients and patients who underwent cardiothoracic surgery were more likely to be responsive. Nonresponders to FCCCI had slightly higher mortality (21 vs. 6.6%, p = 0.05).

CONCLUSIONS

FCCCI resulted in a significant improvement in diuresis with achievement of negative fluid balance in pediatric ICU patients. FCCCI is a reasonable approach to aggressive diuresis in the pediatric patient, particularly in patients with limited access. Serum potassium should be routinely monitored during such therapy.

Use of Fenoldopam in Children with Congenital Heart Disease to Decrease Fluid Balance: A Retrospective, Descriptive Study and Insights into Predictors of Decreased Fluid Balance

This retrospective study aimed to determine if fenoldopam is associated with a decrease in fluid balance and to define the factors that may promote this in children with a history of congenital heart disease at the cardiac intensive care unit (CICU). Patients cared from January 2014 to December 2018 in the CICU were reviewed, and those on fenoldopam infusion were identified. Patient cohort data included demographics, clinical information, laboratory results, hemodynamic and urine output measurements, and information regarding fenoldopam infusion were compared between those with and without decrease in fluid balance. Forty-six patients were identified. Patients received a starting dose of fenoldopam of 0.2 mcg/kg/h, a maximum dose of 0.3 mcg/kg/h, and duration of 64 hours. Over the 4-hour study period, statistically significant change was noted in systolic pressure (decrease of 5.4%; p < 0.001), diastolic pressure (decrease of 3.5%; p = 0.01), fluid balance, and urine output (decrease of 1.3%; p = 0.027). In the cohort, 34 patients (74%) had a decrease in fluid balance, 18 (39%) had an increase in urine output, and 25 (54%) had a decrease in fluid input after the initiation of fenoldopam. Patients that had a decrease in fluid balance tended to have a higher blood urea nitrogen level at the time of fenoldopam initiation. Fenoldopam was associated with decrease in fluid balance and fluid input, but not associated with an increase in urine output. The identification of factors that can decrease fluid balance may help identify those patients who can be benefited with this treatment.

Efficacy of sequential nephron blockade with intravenous chlorothiazide to promote diuresis in cardiac intensive care infants

BACKGROUND

Sequential nephron blockade using intravenous chlorothiazide is often used to enhance urine output in patients with inadequate response to loop diuretics. A few data exist to support this practice in critically ill infants.

METHODS

We included 100 consecutive patients <1 year of age who were administered intravenous chlorothiazide while receiving furosemide therapy in the cardiac ICU in our study. The primary end point was change in urine output 24 hours after chlorothiazide administration, and patients were considered to be responders if an increase in urine output of 0.5 ml/kg/hour was documented. Data on demographic, clinical, fluid intake/output, and furosemide and chlorothiazide dosing were collected. Multivariable regression analyses were performed to determine variables significant for increase in urine output after chlorothiazide administration.

RESULTS

The study population was 48% male, with a mean weight of 4.9±1.8 kg, and 69% had undergone previous cardiovascular surgery. Intravenous chlorothiazide was initiated at 89 days (interquartile range 20-127 days) of life at a dose of 4.6±2.7 mg/kg/day (maximum 12 mg/kg/day). Baseline estimated creatinine clearance was 83±42 ml/minute/1.73 m2. Furosemide dose before chlorothiazide administration was 2.8±1.4 mg/kg/day and 3.3±1.5 mg/kg/day after administration. A total of 43% of patients were categorised as responders, and increase in furosemide dose was the only variable significant for increase in urine output on multivariable analysis (p<0.05). No graphical trends were noted for change in urine output and dose of chlorothiazide.

CONCLUSIONS

Sequential nephron blockade with intravenous chlorothiazide was not consistently associated with improved urine output in critically ill infants.

Managing the Rising Costs and High Drug Expenditures in Critical Care Pharmacy Practice

Pharmaceutical costs for patients in the intensive care unit (ICU) constitute a large portion of hospital drug budgets. Unfortunately, prices for medications commonly used in the ICU are on the rise for a variety of reasons. In particular, the U.S. Food and Drug Administration's Unapproved Drugs Initiative, generic manufacturers cornering the marketplace, drug shortages, and regulatory device changes are major drivers of pharmaceutical price escalation affecting costs in the ICU. Furthermore, traditional high acquisition cost items still pose challenges to controlling costs. To offer strategies to mitigate the rising costs of pharmaceuticals in the ICU setting, we searched the PubMed/Medline and International Pharmaceutical Abstracts databases and other related sources to identify published cost-saving protocols concerning specific medications that are affected by rising prices or have traditional high acquisition costs. In the absence of specific protocols, we offer possible cost-saving initiatives based on published literature regarding specific agents or based on our own diverse set of experiences. Finally, we review suggested clinical and operational activities at an institutional level to address these rising drug costs in the ICU setting.