Diuretic Use in Pediatric Patients After Cardiothoracic Surgery

October 1, 2021

Results from a recently completed quality improvement initiative in the Heart Institute at UPMC Children’s Hospital of Pittsburgh to optimize the use of diuretics (furosemide) in pediatric patients after cardiothoracic surgeries will be published in an upcoming edition of the World Journal for Pediatric and Congenital Heart Surgery.

Former Heart Institute fellow Mira K. Trivedi, MD, is the first author of the paper. Evonne Morell, DO, assistant professor of pediatrics,  director of Inpatient Cardiology and Quality Improvement Director in the Heart Institute at UPMC Children's Hospital, was the study's senior author. Also collaborating on the study was Carlos E. Diaz-Castrillon, MD, from the Division of Pediatric Cardiothoracic Surgery.

Study Details and Key Findings

Standardized guidelines on the use of diuretics postoperatively after pediatric cardiothoracic surgical procedures do not exist. Institutional variations and individual provider practices can vary widely. While the evidence is scarce on the subject, this variability in diuretic use likely means that some patients are receiving more medications for more extended periods than is clinically necessary.

The study team at the Heart Institute devised a standardized diuretic wean protocol for the postoperative period after discharge (10 days) for uncomplicated cases of cardiothoracic surgery. For comparison and analytic purposes, diuretic use was examined and categorized in a cohort of patients who underwent uncomplicated cardiothoracic surgery prior to implementing the protocol (August 2017 to November 2018).The new protocol was considered for all uncomplicated surgical cases within a subset of 10 indications* for congenital heart surgery beginning in November 2018. Data for the study was captured on patients through December 30, 2020 (26 months).

*The ten uncomplicated congenital heart surgeries, defined using The Society of Thoracic Surgery Congenital Heart Surgery Database, were: atrial septal defect; ventricular septal defect; aortic surgeries; semilunar valve surgery; sub/supravalvar resection; conduit replacements; Ross procedure; tetralogy of Fallot repair; coronary anomaly repair.

The study's main objective was to decrease the average duration of diuretic use by 50% versus the baseline usage determined in the pre-protocol period, and to do so with no impact on patient health or increase associated adverse events or readmissions to the hospital. All patients enrolled in the protocol were seen in the clinic two weeks after discharge to assess overall status and health.

The average duration of diuretic use in the pre-protocol period was found to be 32 days after discharge. After the weaning protocol was implemented, the average duration of post-discharge diuretic use in uncomplicated cases of cardiothoracic surgery was reduced to 14 days, reflecting a reduction of 56%.

This reduction in diuretic use was coupled with no increases or changes in the rates of adverse events or hospital readmissions due to fluid or electrolyte disturbances, or pulmonary effusions or edema.

The study conducted by Drs. Trivedi, Diaz-Castrillon, and Morell bodes well for continuing and perhaps expanding or modifying the protocol for other patient cohorts if safety and efficacy can be maintained. Any reduction in the use of the diuretics beyond what is absolutely necessary to ensure the patient's optimal health should be considered a clinical priority. The 56% reduction in furosemide use achieved in this cohort of patients was greater than anticipated at the study's outset. This investigation is the first of its kind to show a marked reduction in the use of single-agent diuretics through a standardized wean protocol in this patient cohort, and the study team is hopeful of continuing this research with larger, collaborative investigations to further explore the feasibility and benefits of the protocol in pediatric cardiothoracic surgery patients.

Learn more about the Heart Institute at UPMC Children’s Hospital of Pittsburgh.

Reference

Trivedi MK, Diaz-Castrillon CE, Morell E. Standardizing Discharge Furosemide Duration Following Congenital Heart Surgery. World J Pediatr Cong Heart Surg. 2021; In Press.