As-needed antihypertensive therapy in surgical patients, why and how: challenging a paradigm

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.