The Cynic's Corner: by Dr. Lubarsky
Just Because We Do It, Don't Make It Right.

Should a Moratorium be Placed on Sublingual Nifedipine Capsules For Hypertensive Emergencies and Pesudoemregencies
JAMA 276:16, p 1328
[ read the abstract ]

This article is important because it suggests that a common practice in the PACU and in the cardiovascular rooms - i.e. giving sublingual nifedipine - is neither efficacious nor safe.

It does not suggest an alternative treatment for the perioperative use of the medication - i.e. patients for whom beta blockers or other anti-hypertensive drugs may not be indicated. I would suggest that IV hydralazine, now available again after a brief discontinuation of its manufacture, is a consideration as a possibly more efficacious arterial dilator. Also, esmolol, which has very limited Beta 2 blocking activity and in the normal dose range has been shown not to significantly impact pulmonary function tests in those with pre-existing COPD, might be another alternative.

Furthermore, unlike nifedipine which has been known to precipitate myocardial infarction according to this article, perioperative beta blockers are the closest thing we have to a truly cardioprotective agent.

I know that I have changed my own practice since this JAMA article was published, and advise others to do the same. From a medico-legal point of view, it might be hard to justify its use in acute perioperative hypertension following this publication.

Is It Time to Pull the Pulmonary Artery Catheter (Editorial)
Dalen JE; Bone RC. JAMA

The Effectiveness of Right Heart Catheterization in the Initial Care of Critically Ill Patients.
Connors AF Jr, et al JAMA
[ read the abstract ]

This is a very important article as it describes the negative outcomes associated with the use of an expensive and invasive technology that anesthesiologists employ daily in their practice. Thousands of critically ill patients with PA catheters were followed, and their physiologic state matched to those not receiving this invasive monitoring. Mortality, cost and length of ICU Stay were all ELEVATED when a pulmonary artery catheter was employed.

Other studies suggest careful application of the data from PA catheters by trained individuals can yield patient care benefits. Regardless, this study shows that indiscriminate use of the PA catheter in the critically ill, especially in teaching institutions where bedside management is often done by young physicians in training, may yield worse patient outcome. Pulmonary artery catheters were introduced and adopted in a widespread fashion without any concrete evidence of clinical benefit.

This article suggests that we should be more careful how we evaluate and employ new technologies, no matter how "apparent" the benefit appears to us physicians.

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