937: Pharmacoeconomic Impact of Diuretic Stewardship in a Pediatric Cardiovascular Intensive Care Unit

Abstract

Introduction: Edema is a common consequence of cardiopulmonary bypass in children after cardiac surgery. High dose diuretics often are used to reverse these effects. Intravenous (IV) ethacrynic acid (EA) is over 900 times more expensive than IV furosemide. Intravenous chlorothiazide (CTZ) costs 360 times more than IV furosemide and approximately 2500 and 220 times more than enteral hydrochlorothiazide and metolazone, respectively. Despite such disparities in cost, IV EA and IV CTZ have been used extensively without optimizing other less expensive, efficacious options. In January 2013 as a cost savings initiative, we developed diuretic stewardship emphasizing the use of IV EA and IV CTZ only when formally indicated. Methods: This retrospective study compares the utilization of IV EA and IV CTZ in pediatric cardiovascular (CV) surgery patients from January to June in 2012 and 2013. All patients admitted to the pediatric CV service were included. EA was considered appropriate in patients with a sulfa allergy. IV CTZ was deemed appropriate in patients receiving IV furosemide >/= 1 mg/kg/dose Q6H or as a continuous infusion >/= 0.2 mg/kg/hr. Data were analyzed with the Mann-Whitney Rank Sum test. Results: There were 149 and 163 cardiovascular surgery cases performed in the first two quarters of 2012 and 2013, respectively. After implementing diuretic stewardship, the use of IV EA was reduced by 90% while IV CTZ use decreased 74%, resulting in overall savings of $130,378 (79%) over a 6 month period. The percentage of appropriate EA doses was unchanged (0%) and increased from 65.8% to 70.2% in the CTZ group. Median ventilator days (IQR) in 2012 and 2013 were not statistically different (1[0-5] vs 1[0-4], respectively, p=0.93). The median ICU length of stay (IQR) was also not statistically different (4[2-8] vs 3[2-6], respectively, p=0.39). Conclusions: A diuretic stewardship program is associated with drastic reduction in the utilization of expensive diuretics without adversely affecting ventilator days and ICU length of stay. Although we recognize many patients may benefit from the use of expensive diuretics, we urge clinicians to escalate therapy with pharmacoeconomic principles in mind. Such a strategy would maximize inexpensive diuretics prior to using other expensive options such as IV EA and IV CTZ.