A retrospective description of anesthetic medication dosing in overweight and obese children

Medication Errors in Overweight and Obese Pediatric Patients: A Narrative Review

BACKGROUND

The childhood obesity epidemic in the United States has increased utilization of health care and prescribing of medications in overweight and obese children, yet it is unclear whether this has led to more medication errors. The objective of this study was to review all available literature on incidence and types of medication errors in overweight and obese children.

METHODS

A search of MEDLINE, Embase, and Scopus databases was conducted for all studies and oral abstracts through December 2020 reporting medication errors in overweight or obese children aged ≤ 18 years. All studies were identified and extracted via a Covidence database. Two reviewers independently reviewed studies and rated the methodologic quality of those included per GRADE (Grading of Recommendations, Assessment, Development and Evaluations) criteria.

RESULTS

The search identified 1,016 abstracts from databases. Following review, full text was obtained for 146 articles, of which 141 were excluded. A total of 5 studies met criteria for inclusion and described dosing errors of antimicrobials, anesthetics, and paracetamol in overweight and obese pediatric patients. Two of the 5 studies compared medication errors in obese to nonobese children, and both found that medication errors (both over- and underdosing) were generally more common among obese children. The identified reasons for medication errors included incorrect dosing weight, incorrect dosing strategy, over- and underdosing with weight-based and flat-fixed dosing, and inapposite use of age-based dosing schemas.

CONCLUSION

There is a paucity of patient safety evidence available evaluating medication use in overweight and obese children and associated medication errors. Overweight and obese children may be at increased risk of medication errors, although the clinical significance of this is unknown.

A Retrospective Review of Opioid Prescribing Practices for At-Risk Pediatric Populations Undergoing Ambulatory Surgery

OBJECTIVE

Pediatric patients with sleep-disordered breathing (SDB) and obesity are at risk for opioid-induced respiratory depression. Although monitoring in the inpatient setting allows for early recognition of opioid-related adverse events, there is far less vigilance after ambulatory surgery as patients are discharged home. Guidelines for proper opioid dosing in these pediatric subsets have not been established. We sought to determine if at-risk children were more likely to receive doses of opioids outside the recommended range.

METHODS

Baseline opioid prescribing data for all outpatient surgery patients receiving an opioid prescription between January 2019 and June 2020 were retrospectively reviewed. Patients with SDB or obesity were identified. To obtain more information about prescribing practices, we analyzed patient demographics, size descriptors used for calculations, and prescription characteristics (dose, duration, and prescribing surgical service).

RESULTS

A total of 4674 patients received an opioid prescription after outpatient surgery. Of those, 173 patients had SDB and 128 were obese. Surgical subspecialties rendering most of the opioid prescriptions included otolaryngology and orthopedics. Obese patients were more likely (64%) to be prescribed opioids using ideal weight at higher mg/kg doses (>0.05 mg/kg; 83.3%; p < 0.0001). When providers used actual body weight, lower mg/kg doses were more likely to be used (53.7%; p < 0.0001). No prescriptions used lean body mass.

CONCLUSIONS

Overweight/obese children were more likely to receive opioid doses outside the recommended range. Variability in prescribing patterns demonstrates the need for more detailed guidelines to minimize the risk of opioid-induced respiratory complications in vulnerable pediatric populations.

A Multicenter Retrospective Study of Vancomycin Dosing by Weight Measures in Children

OBJECTIVE

Vancomycin carries risks of treatment failure and emergent resistance with underexposure and renal toxicity with overexposure. Children with overweight or obesity may have altered pharmacokinetics. We aimed to examine how body weight metrics influence vancomycin serum concentrations and to evaluate alternative dosing strategies.

METHODS

This was a multicenter retrospective cohort study across 3 large, academic hospitals. Patients aged 2 to 18 years old who received ≥3 doses of intravenous vancomycin were included. Weight metrics included total body weight, adjusted body weight, ideal body weight, body surface area, and allometric weight. Outcomes included vancomycin concentration and ratios of area under the curve (AUC) to minimum inhibitory concentration (MIC). Regression analyses were used to examine which body-weight identifier predicted outcomes.

RESULTS

Of the 1099 children, 45% were girls, mean age was 9.0 (SD = 5.4) years, 14% had overweight, and 17% had obesity. Seventy-five percent of children had vancomycin concentrations in the subtherapeutic range by trough <10 µg/mL, and 63% had a ratio of AUC to MIC <400 μg-hr/mL. Three percent had a supratherapeutic initial trough >20 µg/mL or ratio of AUC to MIC >600 μg-hr/mL. Serum vancomycin concentrations were higher in children with overweight or obesity compared with children who were at a normal weight or underweight; the mean ratio of AUC to MIC also trended higher in the groups with overweight or obesity.

CONCLUSIONS

Most children received vancomycin regimens that produced suboptimal trough levels. Children with overweight or obesity experienced higher vancomycin trough levels than children of normal weight despite receiving lower total body weight dosing. Using the ratio of AUC to MIC was a better measure of drug exposure.

An integrative review of method types used in the study of medication error during anaesthesia: implications for estimating incidence

To meet the WHO vision of reducing medication errors by 50%, it is essential to know the current error rate. We undertook an integrative review of the literature, using a systematic search strategy. We included studies that provided an estimate of error rate (i.e. both numerator and denominator data), regardless of type of study (e.g. RCT or observational study). Under each method type, we categorised the error rate by type, by classification used by the primary studies (e.g. wrong drug, wrong dose, wrong time), and then pooled numerator and denominator data across studies to obtain an aggregate error rate for each method type. We included a total of 30 studies in this review. Of these, two studies were national audit projects containing relevant data, and for 28 studies we identified five discrete method types: retrospective recall (6), self-reporting (7), observational (5), large databases (7), and observing for drug calculation errors (3). Of these 28 studies we included 22 for a numerical analysis and used six to inform a narrative review. Drug error is recalled by ~1 in 5 anaesthetists as something that happened over their career; in self-reports there is an admitted rate of ~1 in 200 anaesthetics. In observed practice, error is seen in almost every anaesthetic. In large databases, drug error constitutes ~10% of anaesthesia incidents reported. Wrong drug or dose form the most common type of error across all five study method types (especially dosing error in paediatric studies). We conclude that medication error is common in anaesthetic practice, although we were uncertain of the precise frequency or extent of harm. Studies concerning medication error are very heterogenous, and we recommend consideration of standardised reporting as in other research domains.

Perioperative respiratory adverse events during ambulatory anesthesia in obese children

Obesity is one of the most common clinical conditions in the pediatric population with an increasing prevalence ranging from 20 to 30% worldwide. It is well known that during ambulatory anesthesia, obese children are more prone to develop perioperative respiratory adverse events (PRAEs) associated with obesity. To avoid or at least minimize these adverse effects, a thorough preoperative assessment should be undertaken as well as consideration of specific anesthetic approaches such as preoxygenation before induction of anesthesia and optimizing drug dosing. The use of short-acting opioid and nonopioid analgesics and the frequent implementation of regional anesthesia should also be included. Noninvasive airway management, protective mechanical ventilation, and complete reversion of neuromuscular blockade and awake extubation also proved to be beneficial in preventing PRAEs. During the postoperative period, continuous monitoring of oxygenation and ventilation is mandatory in obese children. In the current review, we sought to provide recommendations that might help to reduce the severity of perioperative respiratory adverse events in obese children, which could be of particular importance for reducing the rate of unplanned hospitalizations and ultimately improving the overall postoperative recovery.

Obesity and Corticosteroid Dosing Guideline Adherence in Children Hospitalized With Asthma

OBJECTIVES

Drug dosing recommendations for children with obesity remain limited. This may lead to variability in medication dosing among children with obesity. Therefore, our objective was to determine differences in the prevalence of guideline-nonadherent systemic corticosteroid orders by weight category in children hospitalized for asthma.

METHODS

We performed a retrospective cross-sectional study of children aged 2 to 17 years hospitalized with asthma and prescribed systemic corticosteroids between January 1, 2010, and December 31, 2017, using the Cerner Health Facts deidentified database. Weight categories ranging from underweight to class III obesity were defined on the basis of BMI percentiles by using CDC guidelines. Corticosteroid orders were categorized as guideline adherent or nonadherent on the basis of total body weight-based dosing guidelines from the National Heart, Lung, and Blood Institute. χ² test and multivariable logistic regression models were used to determine differences in guideline adherence between weight categories.

RESULTS

We identified 21 488 children prescribed systemic corticosteroids during asthma hospitalizations. Most (54.2%) had a healthy weight, and 23.8% had obesity. Almost one-quarter received guideline-nonadherent orders (22.2%), with increasing prevalence among higher weight categories (19.4% of healthy weight children versus 36.0% of those with class III obesity; P < .001). After controlling for demographic and clinical covariates, weight category remained significantly associated with receiving a guideline-nonadherent order (P < .001).

CONCLUSIONS

The prevalence of guideline-nonadherent corticosteroid orders for children hospitalized with asthma increases linearly with weight category, disproportionately affecting children with severe obesity. Standardization of drug dosing guidelines for children with obesity may help reduce variability in drug doses prescribed that may increase risk of harm.

[German S1 guideline: obstructive sleep apnea in the context of tonsil surgery with or without adenoidectomy in children-perioperative management]

Otolaryngologic surgery is one of the most frequent operative interventions performed in children. Tonsil surgery with or without adenoidectomy due to hyperplasia of the tonsils and adenoids with obstruction of the upper airways with or without tympanic ventilation disorder is the most common of these procedures. Children with a history of sleep apnoea (OSA) suffer from a significantly increased risk of perioperative respiratory complications. Cases of death and severe permanent neurologic damage have been reported due to apnoea and increased opioid sensitivity. The current guideline represents a pragmatic risk-adjusted approach. Patients with confirmed or suspected OSA should be treated perioperatively according to their individual risks and requirements, in order to avoid severe permanent damage.

Association between higher BMI and postoperative pain and opioid consumption in pediatric inpatients - A retrospective cohort study

BACKGROUND

Childhood and adolescent obesity increased in recent decades, and caregivers face an increasing number of obese pediatric surgical patients. Some clinical and pharmacogenetic data suggest that obese patients have altered pain sensitivity and analgesic requirements.

OBJECTIVE

To test the primary hypothesis that increased BMI in pediatric patients is associated with increased pain during the initial 48 postoperative hours. Secondarily, we tested whether BMI is associated with increased opioid consumption during the same period.

DESIGN

Retrospective single-center cohort study.

SETTING

Pediatric surgical wards in a tertiary medical center.

PATIENTS

A total of 808 opioid naïve patients aged 8 to 18 years having elective non-cardiac surgery with hospital stay of at least 48 h in the Cleveland Clinic between 2010 and 2015.

INTERVENTIONS

None.

MEASUREMENTS

Using U.S. Centers for Disease Control definitions for childhood weight classifications, we retrospectively evaluated the association between body mass index (BMI) percentile and time-weighted average pain scores and opioid consumption. We used multivariable linear regression to test for an association with postoperative pain scores, and multivariable gamma regression to test for an association with postoperative opioid consumption (in mg morphine equivalents Kg^-1).

RESULTS

BMI was not associated with postoperative pain after general, orthopedic, or neuro-spinal surgeries. Pain increased by 0.07 [98.75% CI: (0.01, 0.13), P_adj < 0.05] points per 5 percentile increase in BMI after neuro-cranial surgery. Higher BMI was associated with a decrease in postoperative opioid consumption (mean change [95% CI] -2.12% [-3.12%, -1.10%] in morphine equivalents Kg^-1 per 5 percentile increase in BMI, P < 0.001).

CONCLUSION

We found no clinically important increase in pain scores or opioid consumption in association with higher BMI in patients 8 to 18 years of age recovering from elective non-cardiac surgery.

Implications of a Retrospective Study on Weight-Based Risk for Post-Tonsillectomy Pain in Children

PURPOSE

The purpose was to examine if children experience weight-based risks for post-tonsillectomy pain (PTP) in the postanesthesia care unit (PACU).

DESIGN

This retrospective correlational cohort design included a sample of 180 children between the ages of 4 to 12 years who had tonsillectomy and adenoidectomy or tonsillectomy before August 2016; half were obese (OB) or overweight (OW).

METHODS

The sample was obtained from children who had surgery at a large pediatric hospital with an attached outpatient surgical center in North Texas. Children were defined as either OB and OW or non-OB and non-OW based on a cutoff of standardized body mass index z scores of 85th percentile and greater per the National Center for Health Statistics. Pain scores were obtained in the PACU after surgery. Early PTP was defined as the most severe pain experienced by a child in the first 15 minutes after extubation. Prolonged PTP was sustained and uncontrolled pain in the PACU.

FINDINGS

OB and OW status did not increase the likelihood of experiencing early PTP when examined by multiple logistic regression controlling for covariates (adjusted odds ratio, 1.391; P = .369). OB and OW status was associated with longer episodes of prolonged PTP (r_s[178] = 0.16; P = .03). OB and OW children were more likely to experience prolonged PTP in the PACU (χ²[1] = 8.353; P = .004), with these children experiencing an average PTP period twice as long as their peers.

CONCLUSIONS

OB and OW children did experience risk for prolonged PTP, averaging sustained pain for approximately twice as long as other children. The increased risk for prolonged PTP in OB and OW children occurred despite well-managed early PTP with rates that matched those of their peers. No weight-based risk for early PTP was observed. Further research is needed in the area of PTP management in OB and OW children.

Practical Challenges-Use of Paracetamol in Children and Youth Who are Overweight or Obese: A Narrative Review

Worldwide, > 380 million children and adolescents are overweight or obese, including 41 million children aged < 5 years. Obesity can change the pharmacokinetic properties of drugs by altering their distribution, metabolism, and elimination. Thus, children who are overweight or obese are at increased risk for receiving inappropriate doses of commonly used drugs, which can result in treatment failure, adverse events, and/or drug toxicity. This review analyzes available data on paracetamol dosing for pain and fever in children and adolescents who are overweight or obese to identify gaps and challenges in optimal dosing strategies. Literature searches using Medline, Embase, and ClinicalTrials.gov were conducted to identify English-language articles reporting paracetamol pharmacokinetics, dosing practices, and guidelines in children and adolescents who are overweight or obese. Of 24 relevant studies identified, 20 were specific to overweight/obese individuals and 15 were specific to children and/or adolescents. Data on paracetamol pharmacokinetics in children and adolescents who are overweight or obese are lacking, and there is no high-quality evidence to guide paracetamol prescribing practices in these patients. Adult data have been extrapolated to pediatric populations; however, extrapolation does not address differences in paracetamol metabolism in adults versus children; the efficacy and safety effects of such differences are unknown. Given the growing worldwide prevalence of obesity in children and adolescents and the likelihood that paracetamol use in this population will increase accordingly, obesity-specific pediatric dosing guidelines for paracetamol are urgently needed. High-quality research is necessary to inform such guidelines.

Framework to Explain the Progression of Pain in Obese or Overweight Children Undergoing Tonsillectomy

An estimated 100,000 obese (OB) and overweight (OW) children undergo tonsillectomy each year in the United States. Pain management in this population is particularly challenging because of weight-based dosing, clinician fears, potential for airway obstruction, and genetic differences. A framework is proposed to explain factors involved in the post-tonsillectomy pain (PTP) experience in OB and OW children. The tonsillectomy, the body's inflammatory state, and mechanical stressors comprise influencing factors in PTP progression. Clinician-delivered medication doses, genetic variants of drug metabolism, and soothing factors serve as mediating factors in the progression of PTP. Postanesthesia care unit (PACU) nurses may use this framework to better understand PTP progression in OB and OW children. PACU nurses may manipulate certain mediating factors discussed in this framework to moderate PTP progression in OB and OW children. Researchers may use this framework to support future research to improve PTP management in OB and OW children.

The Crashing Obese Patient

Emergency physicians (EP) frequently resuscitate and manage critically ill patients. Resuscitation of the crashing obese patient presents a unique challenge for even the most skilled physician. Changes in anatomy, metabolic demand, cardiopulmonary reserve, ventilation, circulation, and pharmacokinetics require special consideration. This article focuses on critical components in the resuscitation of the crashing obese patient in the emergency department, namely intubation, mechanical ventilation, circulatory resuscitation, and pharmacotherapy. To minimize morbidity and mortality, it is imperative that the EP be familiar with the pearls and pitfalls discussed within this article.

Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 1

For decades, the dental profession has provided anesthesia services in office-based, ambulatory settings to alleviate pain and anxiety, ranging from local anesthesia to general anesthesia. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a substantial lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article will illuminate the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medicine has implemented to manage such problems, and introduce a method for addressing these issues with the dental anesthesia medication safety paradigm.

Peri-operative management of overweight and obese children and adolescents

Obesity has become endemic, even in children. Systemic complications associated with obesity include metabolic syndrome, cardiovascular disease, and respiratory compromise. These comorbidities require adequate investigation, targeted optimisation, and, if surgery is required, specific management during the peri-operative period. Specific peri-operative strategies should be used for paediatric patients who are overweight or obese to prevent postoperative complications, and optimising the respiratory function during surgery is particularly crucial. This Review aims to provide up-to-date information on peri-operative management for physicians who are caring for children and adolescents (usually younger than 18 years) who are overweight or obese undergoing surgery, including bariatric surgery. We have particularly focussed on the physiological consequences of obesity-namely, obstructive sleep apnoea, respiratory compromise, and pharmacological considerations.

Accuracy of rapid sequence intubation medication dosing in obese patients intubated in the ED

OBJECTIVE

There are limited data regarding appropriateness of sedative and paralytic dosing of obese patients undergoing rapid sequence intubation (RSI) in the emergency department. The goal of this study was to compare rates of appropriate succinylcholine and etomidate doses in obese and nonobese patients.

METHODS

Retrospective review using a database of endotracheally intubated patients using RSI in an urban, tertiary care academic emergency department, from November 2009 to June 2011. Dosing for succinylcholine and etomidate was calculated as milligrams per kilogram of total body weight (TBW) for each patient, defining appropriate dosing as succinylcholine 1-1.5 mg/kg TBW and etomidate 0.2-0.4 mg/kg TBW. Logistic regression analysis was used to estimate the association between appropriate dosing and World Health Organization body mass index classification.

RESULTS

A total of 440 patients were included in the study, 311 (70.7%) classified as nonobese and 129 (29.3%) as obese. two hundred thirty-three (56%) received an inappropriate succinylcholine dose and 107 (24%) received an inappropriate etomidate dose. Obese patients were more likely to be underdosed with succinylcholine (odds ratio [OR], 63.7; 95% confidence interval [CI], 17.8-228.1) and etomidate (OR, 178.3; 95% CI, 37.6-844.7). Nonobese patients were more likely to be overdosed with succinylcholine (OR, 62.5; 95% CI, 17.9-250) and etomidate (OR, 166.7; 95% CI, 37.0-1000).

CONCLUSION

Obese patients were more likely to be underdosed during RSI compared with nonobese patients, whereas nonobese patients were more likely to be overdosed with RSI medications. Most obese and nonobese patients were inappropriately dosed with RSI medications, suggesting that physicians are not dosing these medications based on weight.

The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium

OBJECTIVES

To evaluate the impact of obesity on adverse events and required interventions during pediatric procedural sedation.

METHODS

The Pediatric Sedation Research Consortium database of prospectively collected procedural sedation encounters was queried to identify patients for whom body mass index (BMI) could be calculated. Obesity was defined as BMI ≥95th percentile for age and gender. Sedation-related outcomes, adverse events, and therapeutic interventions were compared between obese and nonobese patients.

RESULTS

For analysis, 28,792 records were eligible. A total of 5,153 patients (17.9%) were obese; they were predominantly male and older and had a higher median American Society of Anesthesiologists Physical Status classification (P < 0.001). Total adverse events were more common in obese patients (odds ratio [OR] 1.49, 95% confidence interval [1.31, 1.70]). Respiratory events (airway obstruction OR 1.94 [1.54, 2.44], oxygen desaturation OR 1.99 [1.50, 2.63], secretions OR 1.48 [1.01, 2.15], laryngospasm OR 2.30 [1.30, 4.05]), inability to complete the associated procedure (OR 1.96 [1.16, 3.30]), and prolonged recovery (OR 2.66 [1.26, 5.59]) were increased in obese patients. Obese patients more frequently required airway intervention including repositioning, suctioning, jaw thrust, airway adjuncts, and bag-valve-mask ventilation. Multivariate regression analysis demonstrated obesity to be independently associated with minor and moderate but not major adverse events.

CONCLUSIONS

Obesity is an independent risk factor for adverse respiratory events during procedural sedation and is associated with an increased frequency of airway interventions, suggesting that additional vigilance and expertise are required when sedating these patients.