As-Needed Antihypertensive Therapy in Surgical Patients, Why and How: Challenging a Paradigm

Abstract

Hypertension is common in hospitalized patients and there are many causes. Some patients have no prior history of hypertension, few symptoms, and no apparent morbidity related to acute rises in blood pressure. Though there is no established guideline for therapy in these cases, patients often receive therapy directed at the abnormal vital sign. It is hypothesized that this practice is common and the associated costs are significant. Using the inpatient pharmacy database at the University of Kentucky Chandler Medical Center, a verified Level I trauma center and quaternary referral center, patients on the emergency general surgery or orthopedic surgery services receiving intravenous hydralazine, metoprolol, or labetalol were identified. Subjects were analyzed for indications, parameters, associated history of hypertension, and direct costs. Over the 4-month study period, 114 subjects received 522 drug doses. More than half (55%) of subjects had a prior history of hypertension but only 75 per cent were started on their home medication. Of those without hypertension before admission, 18 per cent required therapy at discharge. Labetalol was the most frequently used agent and total pharmacy costs for this cohort of patients was over $1200. Pro re nata (PRN), short-acting antihypertensive therapy has little evidence base in asymptomatic patients, but its prevalence is high on surgical services. The cost is significant, especially when extrapolated to the larger hospital population at this single institution. Further research is warranted to determine the prevalence of this practice in other centers or national regions, as well as its cost and benefit.

Retrospective review of the use of as-needed hydralazine and labetalol for the treatment of acute hypertension in hospitalized medicine patients

“…Other possible causes for acute severe blood pressure elevations in hospitalized patients include uncontrolled pain from a medical condition, trauma or surgery, acute volume overload, anxiety, or newly started medications known to increase blood pressure. 10,11,17 We were unable to adequately assess these possible causes in our study.…”

“…These studies have also documented a wide variability in dosing and the lack of proper patient evaluation prior to antihypertensive medication administration. 5,[10][11][12][13] This variability in administration practices may be attributed to the paucity of literature guiding healthcare providers on the management of severe asymptomatic hypertension in the hospitalized patient. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure states that the term 'hypertensive urgency' has led to overly aggressive treatment of patients with severe, uncomplicated hypertension.…”

“…Several studies have demonstrated the inappropriate use of PRN intravenous (IV) hydralazine and labetalol for the management of severe blood pressure elevations in hospitalized patients. [10][11][12][13] In these studies, IV antihypertensives were frequently administered to patients that did not meet criteria for acute severe hypertension. In addition, patients were often not continued on their home antihypertensive medications prior to administration of a PRN IV antihypertensive agent.…”

“…9 There are several reasons a patient may have acute elevations in blood pressure while hospitalized such as: uncontrolled pain from trauma/surgery or a medical condition, volume overload, anxiety, new medications that increase blood pressure, or having home antihypertensive medications held. 10,11 Since there is a lack of data guiding the management of severe elevations in blood pressure, these patients are frequently and inconsistently managed with as-needed (PRN) antihypertensive medications.…”

Hypertension in the Pediatric Intensive Care Unit

“…Of those patients, 18% were sent home on an antihypertensive agent. 38 Hypertension after tractional orthopedic surgeries is also very common. Heij et al have found an arterial hypertension incidence of 62% in children treated with skeletal traction for forearm and leg fractures and orthopedic diseases.…”