Clinical Pediatrics http://cpj.sagepub.com/
Pediatric Obesity and Safety in Inpatient Settings: A Systematic Literature Review Elizabeth E. Halvorson, Megan B. Irby and Joseph A. Skelton CLIN PEDIATR 2014 53: 975 originally published online 6 May 2014 DOI: 10.1177/0009922814533406 The online version of this article can be found at: http://cpj.sagepub.com/content/53/10/975
Published by: http://www.sagepublications.com
Additional services and information for Clinical Pediatrics can be found at: Email Alerts: http://cpj.sagepub.com/cgi/alerts Subscriptions: http://cpj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Jul 31, 2014 OnlineFirst Version of Record - May 6, 2014 What is This?
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
533406
research-article2014
CPJXXX10.1177/0009922814533406Clinical PediatricsHalvorson et al
Article
Pediatric Obesity and Safety in Inpatient Settings: A Systematic Literature Review
Clinical Pediatrics 2014, Vol. 53(10) 975–987 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814533406 cpj.sagepub.com
Elizabeth E. Halvorson, MD1, Megan B. Irby, MS1,2, and Joseph A. Skelton, MD, MS1,2,3
Abstract Objective. Pediatric obesity affects more than 16% of American children and is associated with worse outcomes in hospitalized patients. A systematic literature review was performed to identify studies of adverse care events affecting obese pediatric patients in the emergency room, operating room, or inpatient wards. Evidence Review. We systematically searched Medline for articles published from 1970 to 2013 regarding obesity and patient safety events in pediatric acute care settings. We determined the study design, number of patients studied, definition and prevalence of obesity, the relevant acute care setting, the specific association with obesity addressed, and the results of each study. Results and Conclusion. Thirty-four studies documented both procedural complications and issues with general hospital care. Most were retrospective and focused on surgery or anesthesia. Obese patients may have increased risk for a variety of adverse events. Further study could improve institutional patient safety guidelines to enhance care for obese children. Keywords pediatric, obesity, safety, inpatient, surgery
Introduction Pediatric obesity is a significant public health concern, as 16.9% of American children are currently obese, representing a tripling since 1980.1 Obese children are at higher risk for several chronic conditions, including diabetes,2 obstructive sleep apnea,3 nonalcoholic fatty liver disease,4 and gallbladder disease,5 both during childhood and into adulthood. Furthermore, obese children may become more ill if they have several common pediatric conditions, including asthma6 and influenza.7,8 One recent review demonstrated a trend toward increased mortality and increased rate of infections in obese patients who require hospitalization,9 and several studies support that obese inpatients have longer hospital length of stay9-13 and higher hospital charges10,13 than their normal-weight counterparts. Patient safety, brought to national attention with the publication of the Institute of Medicine’s To Err is Human14 and Crossing the Quality Chasm,15 focuses on preventable measures that may adversely affect the outcomes discussed above. The Agency for Healthcare Research and Quality has defined a number of pediatricspecific quality indicator events. These focus on procedure-based complications including accidental
punctures, iatrogenic pneumothoraces, hospital-acquired infections, and postoperative complications. A review of discharges from 38 children’s hospitals in the United States revealed that these events can prolong length of stay as long as 23.5 days in the case of postoperative sepsis and may result in up to $337,226 in excess hospital charges.16 Furthermore, obese patients may face issues with general hospital care unrelated to procedures. For example, medication dosing is typically weight-based in children; thus, appropriate dosing and pharmacokinetics for an obese patient may not be evident.17 Although obese children are known to have poor clinical outcomes, it is unclear whether adverse patient-care 1
Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA 2 Brenner FIT Program, Brenner Children’s Hospital, Winston-Salem, NC, USA 3 Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA Corresponding Author: Elizabeth E. Halvorson, Department of Pediatrics, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
976
Clinical Pediatrics 53(10)
events are a contributing factor. This knowledge could change institutional patient safety protocols, many of which do not specifically address obese patients.18,19 In this systematic literature review, we identified studies of patient safety issues in obese children and asked whether obesity contributes to increased mortality, prolonged length of stay, and increased hospital charges. We hypothesize that obese inpatient children and adolescents are at greater risk for adverse patient-care events, which may contribute to overall poorer outcomes and increased medical costs.
Methods We systematically searched Medline (PubMed) from 1970 to April 2013 for English-language manuscripts of children (birth to 18 years old), treated within acute care settings, specifically inpatient hospitalizations, emergency department visits, surgical operations, or other acute inpatient procedures. We focused on studies that identified overweight or obese children as a specific subpopulation in their analysis. Referenced articles of relevance within these studies were also extracted and included. There is no universal definition of patient safety. For this review, we conceptualized patient safety to incorporate issues specific to procedures and general hospital care. For procedural complications, we focused on many of the Agency for Healthcare Research and Quality pediatric-specific quality indicator events, including accidental lacerations or punctures, decubitus ulcers, retained foreign body, iatrogenic pneumothoraces, hospital-acquired infections, and perioperative hemorrhage, respiratory failure, sepsis, and wound dehiscence.16,20 Under general hospital care, we included patient issues related to blood products, environment, equipment or medical devices, falls, laboratory errors, medications, and radiology.21 Terms used for the literature search were pediatric obesity in combination with one of the following terms: safety, acute care, trauma, hospitalization, admission, iatrogenic, falls, thrombosis, infection, screening, pneumothorax, transfusion, foreign body, and errors. Study titles and abstracts were initially reviewed for inclusion criteria, specifically pediatric obesity, any element of patient safety identified above, and patients within the hospital, emergency department, or operating room settings. Studies were excluded if they were not available in English, included only adult patients, were conducted outside of an acute care setting, did not compare an overweight/obese population with a normal-weight population, or were not specific to a patient safety issue identified above. Data extracted from each study included the study design, number of patients studied, definition
and prevalence of obesity, the relevant acute care setting, the specific question or association with obesity addressed, and the results. The primary investigator (EEH) independently screened all titles and abstracts identified in the search, and obtained full texts for articles meeting inclusion criteria or if abstracts lacked sufficient information to determine inclusion. Full-text articles were then reviewed to determine inclusion and were classified based on patient safety topic into one of 2 broad categories: procedural complications and general hospital care. Articles were classified based on the type of study and were grouped based on patient safety classification and study design for analysis.
Results A total of 402 studies met the initial search criteria and were reviewed for inclusion. Applying the criteria noted above narrowed this group to 34 studies, which were included in the final analysis. The search results are displayed in Figure 1. Studies identified possible safety issues associated with obesity across many topics. Articles were reviewed and grouped by general patient safety areas as defined above: procedural complications (n = 22) and general hospital care (n = 12). Overall, most studies (n = 22) were retrospective. Table 1 lists studies that focused on complications from procedures, specifically accidental punctures, decubitus ulcers, retained foreign bodies, thrombosis, iatrogenic pneumothoraces, hospital-acquired infections, and perioperative complications (both airway related and non–airway related). Most studies focused on perioperative complications; several demonstrated increased risk of airway obstruction and oxygen desaturation during sedation.13,22-24 No other perioperative complications were consistently associated with obesity. A few studies suggested increased risk of decubitus ulcers25 and thrombosis25-28 in obese patients. Table 2 lists studies related to safety issues affecting general hospital care. Several articles were relevant to the safety of equipment and medical devices when used in obese children. For example, the Broselow tape (used to estimate weight in emergency settings) frequently underestimated weight in obese children.44-46 Furthermore, a retrospective chart review by Miller et al47 demonstrated a statistically significant increase in dosing errors for overweight patients. Studies focused on anticoagulation reported difficulties in attaining therapeutic drug levels in obese patients.48,49 Additional studies addressed radiologic issues50,51 and the predictive value of C-reactive protein52 in obtaining a diagnosis of appendicitis in obese patients. No studies specifically addressed blood product safety or falls.
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
977
Halvorson et al
Total References Generated 402
Full Texts Reviewed for Inclusion 96
Excluded: Failed to meet Inclusion Criteria 306
Excluded from Analysis 62 1 No menon of obesity 1 Adult only 3 Non-acute 6 No comparison group 11 reviews 40 No relevant safety event
Included in Final Analysis 34
Procedural Complica ons 22 18 Retrospecve 3 Prospecve 1 Case Report
General Safety 12 4 Retrospecve 5 Prospecve 2 Survey 1 Case Report
Figure 1. Decision tree for results of literature review searches.
Few studies assessed clinical outcome following the adverse safety event, and none addressed subsequent mortality or hospital charges. Only 7 of the studies assessed length of stay. A recent review suggests that obese children tend to have longer hospital stays than normal-weight children.9 Some studies support this finding, specifically a report of children undergoing adenotonsillectomy for sleep-disordered breathing,22 in which obese children had a higher rate of perioperative complications. Nafiu et al13 also found that body mass index had a positive correlation with length of stay in patients undergoing adenotonsillectomy. However, no difference in hospital length of stay or rate of perioperative complications was seen between normal-weight, overweight, and obese children in patients undergoing ultrasound for diagnosis of appendicitis50 or laparoscopic cholecystectomy.40
Discussion We performed a systematic literature review to assess the incidence of adverse patient-care events and overall safety in obese children in the acute care setting. Our
goals were to determine if patient safety was compromised for obese children compared with normal-weight children; if patient safety issues contribute to the documented increases in mortality, length of stay, and hospital charges incurred by obese patients; and if specific issues could be identified for inclusion in institutional patient safety protocols. To our knowledge, this is the first literature review targeting the topic of pediatric obesity and patient safety. We found clear evidence that obesity influences patient safety in 4 major fields: medication safety, venous thromboembolism, surgery, and airway management. Several studies addressed issues of medication dosing,47-49 although none assessed the effects of medication over- or underdosing. Since medications are typically dosed based on weight or body surface area, appropriate dosing may be difficult to determine for obese patients. Furthermore, medications may be distributed throughout the body differently based on body composition, thus affecting medication efficacy. Drug pharmacokinetics are frequently altered in obese patients, which may be especially problematic in medications with a narrow therapeutic window.17 Studies
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
978
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Citation/Site
Population Analyzed
BMI >95%; 294 obese, 1020 nonobese
Obesity/Overweight Definition
Hanevold et al,28 database, United States
1314 pediatric trauma Rana et al,25 single center, United States patients
Hospital-acquired infection Petnehazy et al,31 single 94 patients undergoing center, Austria appendectomy
Iatrogenic pneumothorax Harwood et al,30 single 107 children >5 years center, United States old undergoing blind percutaneous liver biopsy
Vu et al,27 database, United States
Findings
Prospective
Retrospective Increased rate of decubitus ulcer complicating injuries to obese patients
Study Design
Perioperative complications, including pneumothorax, following blind percutaneous liver biopsy
Severity of traumatic injury
Outcomes after renal transplant
Retrospective No significant difference in biopsy success or complication rate between obese and nonobese patients
Retrospective Obese patients younger, shorter, and had been on dialysis longer before transplant. Obese children 6-12 years more likely to die than nonobese counterparts. More likely to lose graft due to thrombosis if obese Retrospective Increased rate of venous thromboembolism complicating injuries to obese patients
(continued)
BMI >95%; 29 obese, 65 nonobese Perioperative Retrospective No significant difference in operative complications time between obese and nonobese from single-port patients. One wound healing appendectomy complication in obese group; one postoperative bleeding and one wound infection in nonobese group
Obese BMI >95% (n = 30); nonobese BMI 95%; 294 obese, 1020 nonobese
16 cases of patients diagnosed with pulmonary embolus 1 651 196 hospital admissions included in database 6658 pediatric patients BMI >95%; 649 obese, 6009 following renal transplant nonobese
Tavil et al,29 single center, Turkey
Risk of cerebral venous thrombosis
Severity of traumatic injury
Study Question
Combination of prothrombotic risk factor with underlying condition (including obesity) increased risk of cerebral venous thrombosis No definition, 1 case described as Risk of pulmonary Retrospective One patient with pulmonary embolism obese embolus had obesity associated with operated craniopharyngioma ICD-9 code for obesity as Risk factors for Retrospective Obese patients at higher risk of DVT discharge diagnosis DVT than nonobese
Thrombosis Heller et al,26 database, 149 patients with cerebral No definition, 2 cases described Germany venous thrombosis, ages as obese 0-18 years
Accidental lacerations/punctures Decubitus ulcer 1314 pediatric trauma Rana et al,25 single center, United States patients
Patient Safety Issue
Table 1. Patient Safety Events Related to Procedures.
979
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Davies et al,34 single center, Canada
176 patients undergoing Linam et al,35 single center, United States spinal fusion
Study Question
Study Design
Fung et al,22 single center, Canada 49 obese patients + matched controls undergoing adenotonsillectomy for sleep-disordered breathing
Findings
Morbidly obese BMI >95% Incidence of sepsis Retrospective No significant differences in sepsis, (n = 144); obese BMI 90% to 95% multiple organ failure, or mortality (n = 83); overweight BMI 85% to 90% (n = 50); normal BMI 95% (n = 54); lean Incidence of sepsis Retrospective Increased incidence of sepsis and BMI 2 SD over Length of stay, Retrospective Trend toward increased incidence mean (n = 31); moderately obese incidence of of wound infection in very obese weight >1.5 SD over mean (n = wound infection patients with perforated appendicitis, 25); normal weight (n = 226) but not statistically significant. Longer length of stay in very obese patients 44 case patients who developed Rate of obesity Retrospective Obesity with BMI >95% was significant surgical site infection each with BMI >95% risk factor associated with surgical matched to 3 controls who did in cases versus site infection not controls
Obesity/Overweight Definition
Overweight BMI 90% to 95% or obese BMI >95%; 49 obese, 49 matched nonobese
Incidence of postoperative respiratory complications
(continued)
No effect of BMI on gastric fluid volumes before anesthesia (indirect measure of aspiration risk). Emesis on induction occurred in 8 patients (50% obese, 75% with obstructive sleep apnea), but no aspiration events Retrospective Obesity significantly increases risk of postoperative complications, including major events. Obese children had significantly more upper airway obstruction and longer hospital length of stay
Operative complications—Airway 1000 day surgery patients Lean BMI 25% to 75% (n = 424); Risk of aspiration Prospective Cook-Sather et al,36 single center, United overweight BMI 85% to 95% (n = during anesthesia States 140); obese BMI >95% (n = 133)
282 patients undergoing appendectomy
316 trauma patients Brown et al,33 single center, United States
Population Analyzed
Kraft et al,32 single 592 patients with >30% center, United States body surface area burn
Citation/Site
Patient Safety Issue
Table 1. (continued)
980
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Fung et al,22 single center, Canada 49 obese patients plus matched controls undergoing adenotonsillectomy for sleep-disordered breathing
Operative complications—Other 592 patients with >30% Kraft et al,32 single center, United States body surface area burn
Overweight BMI 90% to 95% or obese BMI >95%; 49 obese, 49 matched nonobese
Overweight BMI >85%, 47% overweight
Findings
Retrospective Most patients had uncomplicated recovery. Some required supplemental oxygen or repositioning, very few required positive-pressure ventilation, none required reintubation Retrospective Weight percentiles higher in children with one or more adverse events, but not statistically significant Retrospective Overweight and obese patients more likely to have difficult airway, upper airway obstruction in the PACU, PACU stay longer than 3 hours, and need for 2 or more antiemetics. No significant difference in rate of unplanned hospital admission Retrospective Higher incidence of intraoperative oxygen desaturation and unexpected overnight hospitalization for obese patients Prospective Obese children had higher prevalence of comorbid conditions, including asthma, diabetes, hypertension, and sleep apnea. Higher incidence of oxygen desaturation, difficult mask ventilation, and airway obstruction
Study Design
(continued)
Incidence of sepsis, Retrospective No significant difference in sepsis, multiple organ multiple organ failure, or mortality failure, and death Incidence of Retrospective Obesity significantly increases risk postoperative of postoperative complications, respiratory including major events. Obese complications children had significantly more upper airway obstruction and longer hospital length of stay
Overweight BMI 85% to 95% (n Incidence of = 875); obese BMI >95% (n = perioperative 1048); normal weight BMI 95%; 31% patients Incidence of Petnehazy et al,31 single 94 patients undergoing Retrospective No significant difference in operative center, Austria single-port obese perioperative time between obese and nonobese appendectomy complications patients. One wound healing complication in obese group; one postoperative bleeding and one wound infection in nonobese group Need for Retrospective 4/20 morbidly obese patients required Tweedie et al,42 single 1735 patients undergoing Morbid obesity (n = 20) center, United tonsillectomy and/or postoperative PICU admission; most also had other Kingdom adenoidectomy PICU admission comorbidities 1383 obese children Extremely obese BMI >2 SD over Efficacy of open Retrospective Laparoscopic surgery in obese children Kutasy et al,43 single center, Ireland who underwent mean; 238 extremely obese, vs laparoscopic associated with significantly shorter appendectomy 1145 nonobese approach operating time, lower complication rate, and lesser postoperative analgesia
312 patients undergoing Garey et al, single center, United States laparoscopic cholecystectomy
40
Citation/Site
Abbreviations: BMI, body mass index; ICD-9; International Classification of Diseases, Ninth Revision; DVT, deep venous thrombosis; ICU, intensive care unit; SD, standard deviation; PACU, pediatric acute care unit; ARDS, acute respiratory distress syndrome.
Patient Safety Issue
Table 1. (continued)
982
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Citation/Site
19/47 survey responses from NACHRI member hospitals
Population Analyzed
Nafiu et al,53 single center, United States Sinha et al,44 single center, United States Milne et al,45 one urban and one rural health center, Canada Rosenberg et al,46 single center, United States
Falls Laboratory Kutasy et al,52 single center, Ireland
Study Design
BMI z scores calculated using CDC guidelines
No definition
947 patients who underwent appendectomy
Findings
Accuracy of weight Prospective estimation using Broselow tape Accuracy of weight Prospective estimation using Broselow tape
Extremely obese BMI Predictive value of >2 SD over mean; 164 C-reactive protein in extremely obese, 783 diagnosis of appendicitis nonobese
Retrospective
(continued)
Obese patients significantly more likely to have negative appendectomy. C-reactive protein more elevated in obese patients with negative appendectomy than nonobese patients with negative appendectomy. Specificity and positive predictive value significantly lower
Broselow tape more accurate than physician estimation for normal-weight but not obese children
Obese children more likely to have failed first attempt at cannulation and to require 2 or more attempts Length-based weight estimation underestimates weight with worst underestimation for largest children Weight estimate correlates with actual weight but underestimates it
Hospitals with a bariatric surgery program seem better-prepared for severely obese patients; 95%; to address airway 45 freestanding severely obese BMI management, drug dosing, children’s >95% or BMI >40 or and equipment needs of hospitals to weight >260 lb obese patients? assess degree of preparation Obese BMI >95%; 47 Ease of peripheral IV access Prospective obese, 56 nonobese in obese patients
Obesity BMI >95%
Obesity/Overweight Definition
372 patients presenting Overweight BMI 85% to Accuracy of weight Prospective to ED (157 95% (n = 39) tape from BMI measures
103 patients undergoing IV cannulation 231 pediatric trauma patients, ages 0-14 years 6361 patients with height and weight measured
Equipment/medical device safety 28/45 survey Porter et al,19 survey, United responses from States freestanding children’s hospitals
Behavior Blood product Environmental safety Young et al,18 survey, United States
Patient Safety Issue
Table 2. Patient Safety Events Related to General Hospital Care.
983
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Citation/Site
Population Analyzed
Obesity/Overweight Definition
Risk factors for elevated international normalized ratio on warfarin therapy Concern for underdosing enoxaparin for DVT prophylaxis in obese patients Case report
Retrospective
Retrospective
Study Design
263 patients Obese BMI >85%; 76 undergoing obese, 187 nonobese screening ultrasound for suspected appendicitis
1228 patients undergoing appendectomy
Sulowski et al,50 single center, Canada
Kutasy et al,51 single center, Ireland
Does ultrasound for Prospective diagnosis of appendicitis in obese children lead to favorable outcome: (1) nonperforated appendicitis or other diagnosis undergoing appropriate surgical procedure within 24 hours without CT scan or (2) no appendicitis and discharged from ED within 24 hours without CT scan Extremely obese BMI Incidence of negative Retrospective >2 SD over mean, 207 appendectomy in obese extremely obese, 1021 patients nonobese
298 admissions for 184 Obese BMI >95%, 22.5% Moffett et al,48 single center, patients on warfarin obese United States BMI 105.9, 85.7, and 29.9 Lewis et al,49 single 3 cases of obese center, United patients kg/m2, all >95% States
Incidence of medication over- or underdosing in overweight patients
Study Question
Incidence of negative appendectomy significantly higher in obese than nonobese patients. Sensitivity, specificity, and predictive value of ultrasound significantly lower in obese patients
Similar rate of favorable outcomes, rate of hospitalization, median hospital length of stay, rate of return ED visit, and time to surgery. Obese patients more likely to undergo CT scan within 30 days of initial presentation
Statistically significant increase in dosing errors for overweight patients, with underdosing occurring more frequently than overdosing Obesity was an independent variable associated with nonelevated international normalized ratio Three cases of obese pediatric inpatients all required greater than adult maximum doses of enoxaparin to reach therapeutic anti–factor Xa levels
Findings
Abbreviations: NACHRI, National Association of Children’s Hospitals and Related Institutions; BMI, body mass index; IV, intravenous; CDC, Centers for Disease Control and Prevention; ED, emergency department; SD, standard deviation; DVT, deep venous thrombosis; CT, compute dtomography.
Radiology
Medication issues Miller et al,47 single 839 admissions for 699 Overweight BMI >85%, center, United patients admitted to 33% of all admissions States the hospital
Patient Safety Issue
Table 2. (continued)
984
Clinical Pediatrics 53(10)
defining appropriate dosing for specific medications have demonstrated these difficulties. Olutoye et al54 prospectively determined the effective dose of propofol for induction of anesthesia in obese children and found it to be lower (in weight-based dosing) than that for normalweight children. Since obese children may be receiving inappropriate doses of medications, it will be important to determine the incidence of adverse drug events in this population. Similarly, several studies, mostly retrospective database reviews, suggested that obesity may contribute to an increased incidence of thrombosis; however, they also noted that patients who experienced venous thromboembolism typically had other risk factors, such as presence of a central venous catheter, limited mobility, use of oral contraceptives, or coexisting malignancy or fracture.25-29 In adults, obesity is a clear risk factor for venous thromboembolism55 and is frequently included in guidelines for prophylaxis. There is increasing interest in the potential need for prophylaxis in children,56,57 so definitive determination of the risk conferred by obesity will be crucial as these pediatric guidelines are developed. Most studies reviewed here focused on surgery and anesthesia. Two separate studies by Kutasy et al51,52 demonstrated an increased incidence of unnecessary appendectomy in obese children, attributed to the decreased specificity and positive predictive value of C-reactive protein and ultrasound for diagnosis. Researchers also found that certain operative techniques may be more appropriate for obese pediatric patients.31,43 An example is the use of laparoscopic appendectomy, which resulted in shorter operating time, lower complication rate, and less need for postoperative analgesia in pediatric obese patients.43 Multiple studies raised concerns about obese patients undergoing sedation or general anesthesia. Many demonstrated increased incidence of upper airway obstruction13,22,24 and oxygen desaturation.23,24,58 In the study by Shine et al,37 however, most obese children had an uneventful recovery following anesthesia for adenotonsillectomy. Data on the incidence of wound infections and sepsis are mixed; several studies33-35 reported trends toward increased incidence in obese patients compared with nonobese, while other studies found no difference between the populations. The incidence of other perioperative complications, such as wound dehiscence or postoperative bleeding, was not higher among obese pediatric patients compared with nonobese.31,32,40 However, small sample sizes and retrospective study design limit the interpretation of these reports. For many other types of patient safety events, no studies have been done to assess obesity as a potential
contributing factor. Although one study indicated that the first attempt at peripheral intravenous cannulation was more likely to fail in obese children,53 no studies specifically assessed the number of accidental punctures or lacerations in such patients. Additionally, no studies examined the risk of falls in obese inpatients. There is evidence that obese children sustain increased extremity fractures25 and rib and pelvic injuries59 following trauma compared with nonobese patients, so falls in this population could lead to a worse outcome. Use of hospital equipment not optimized for obese patients could also contribute to increased risk of falls in this population. Several studies assessed the need for enhanced hospital preparation when treating obese pediatric patients. In 2 survey-based studies, only 37% of children’s hospitals have a policy in place to identify and treat overweight or obese patients,18 and 95%, a measure which fails to account for actual body composition. Many articles were single-center reports, which may limit the generalizability of the results to broader and more diverse populations. Furthermore, most studies were retrospective and therefore could not address causative effects of obesity relative to patient safety events. Some studies did identify areas in which pediatric obesity affects issues of patient safety. These areas are disparate and often very specific, such as the use of Broselow tape for estimating weights in acute situations44-46 or the efficacy of different diagnostic measures for appendicitis.50-52 However, in many areas there is only preliminary or theoretical evidence that obesity
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
985
Halvorson et al may contribute to errors, as in medication dosing. It remains unknown whether patient safety errors contribute to the increased mortality, prolonged length of stay, and greater hospital charges incurred by obese pediatric patients. Further studies may help influence the development of institutional policies and protocols to improve the safety of obese pediatric inpatients. Acknowledgments The authors would like to thank Karen Klein (Translational Science Institute, Wake Forest School of Medicine) for providing helpful edits to this article.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by a grant from NICHD/NIH Mentored Patient-Oriented Research Career Development Award K23 HD061597 (JAS).
References 1. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303:242-249. 2. Dabalea D, Bell RA, D’Agostino RB Jr, et al. Incidence of diabetes in youth in the United States. JAMA. 2007;297:2716-2724. 3. Gozal D, Kheirandish-Gozal L. Childhood obesity and sleep: relatives, partners, or both? A critical perspective on the evidence. Ann N Y Acad Sci. 2012;1264:135-141. 4. Giorgio V, Prono F, Graziano F, Nobili V. Pediatric nonalcoholic fatty liver disease: old and new concepts on development, progression, metabolic insight and potential treatment targets. BMC Pediatr. 2013;13:40. 5. Mehta S, Lopez ME, Chumpitazi BP, Mazziotti MV, Brandt ML, Fishman DS. Clinical characteristics and risk factors for symptomatic pediatric gallbladder disease. Pediatrics. 2012;129:e82-e88. 6. Carroll CL, Bhandari A, Zucker AR, Schramm CM. Childhood obesity increases duration of therapy during severe asthma exacerbations. Pediatr Crit Care Med. 2006;7:527-531. 7. Chen WH, Lu CY, Shao PL, et al. Risk factors of severe novel influenza A(H1N1) infections in hospitalized children. J Formos Med Assoc. 2012;111:421-426. 8. Plessa E, Diakakis P, Gardelis J, Thirios A, Koletsi P, Falagas ME. Clinical features, risk factors, and complications among pediatric patients with pandemic influenza A (H1N1). Clin Pediatr (Phila). 2010;49:777-781.
9. Bechard LJ, Rothpletz-Puglia P, Touger-Decker R, Duggan C, Mehta NM. Influence of obesity on clinical outcomes in hospitalized children: a systematic review. JAMA Pediatr. 2013;167:476-482. 10. Woolford SJ, Gebremariam A, Clark SJ, Davis MM. Persistent gap of incremental charges for obesity as a secondary diagnosis in common pediatric hospitalizations. J Hosp Med. 2009;4:149-156. 11. Woolford SJ, Gebremariam A, Clark SJ, Davis MM. Incremental hospital charges associated with obesity as a secondary diagnosis in children. Obesity (Silver Spring). 2007;15:1895-1901. 12. O’Connor J, Youde LS, Allen JR, Baur LA. Obesity and under-nutrition in a tertiary paediatric hospital. J Paediatr Child Health. 2004;40:299-304. 13. Nafiu OO, Chimbira WT, Woolford SJ, Tremper KK, Reynolds PI, Green GE. Does high BMI influence hospital charges in children undergoing adenotonsillectomy? Obesity (Silver Spring). 2008;16:1667-1671. 14. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999. 15. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 16. Kronman MP, Hall M, Slonim AD, Shah SS. Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: a multicenter study of freestanding children’s hospitals. Pediatrics. 2008;121:e1653-e1659. 17. Cheymol G. Effects of obesity on pharmacokinet ics implications for drug therapy. Clin Pharmacokinet. 2000;39:215-231. 18. Young KL, Demeule M, Stuhlsatz K, et al. Identification and treatment of obesity as a standard of care for all patients in children’s hospitals. Pediatrics. 2011;128(suppl 2): S47-S50. 19. Porter RM, Thrasher J, Krebs NF. Implementing a pediatric obesity care guideline in a freestanding children’s hospital to improve child safety and hospital preparedness. J Pediatr Nurs. 2012;27:707-714. 20. Dynan L, Goudie A, Smith RB, Fairbrother G, Simpson LA. Differences in quality of care among non-safetynet, safety-net, and children’s hospitals. Pediatrics. 2013;131:304-311. 21. Chamberlain JM, Shaw KN, Lillis KA, et al; Pediatric Emergency Care Applied Research Network. Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network. Pediatr Emerg Care. 2013;29:125-130. 22. Fung E, Cave D, Witmans M, Gan K, El-Hakim H. Postoperative respiratory complications and recovery in obese children following adenotonsillectomy for sleepdisordered breathing: a case-control study. Otolaryngol Head Neck Surg. 2010;142:898-905. 23. Setzer N, Saade E. Childhood obesity and anesthetic morbidity. Paediatr Anaesth. 2007;17:321-326.
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
986
Clinical Pediatrics 53(10)
24. Tait AR, Voepel-Lewis T, Burke C, Kostrzewa A, Lewis I. Incidence and risk factors for perioperative adverse respiratory events in children who are obese. Anesthesiology. 2008;108:375-380. 25. Rana AR, Michalsky MP, Teich S, Groner JI, Caniano DA, Schuster DP. Childhood obesity: a risk factor for injuries observed at a level-1 trauma center. J Pediatr Surg. 2009;44:1601-1605. 26. Heller C, Heinecke A, Junker R, et al; Childhood Stroke Study Group. Cerebral venous thrombosis in children: a multifactorial origin. Circulation. 2003;108:1362-1367. 27. Vu LT, Nobuhara KK, Lee H, Farmer DL. Determination of risk factors for deep venous thrombosis in hospitalized children. J Pediatr Surg. 2008;43:1095-1099. 28. Hanevold CD, Ho PL, Talley L, Mitsnefes MM. Obesity and renal transplant outcome: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatrics. 2005;115:352-356. 29. Tavil B, Kuskonmaz B, Kiper N, Cetin M, Gumruk F, Gurgey A. Pulmonary thromboembolism in childhood: a single-center experience from Turkey. Heart Lung. 2009;38:56-65. 30. Harwood J, Bishop P, Liu H, Nowick M. Safety of blind percutaneous liver biopsy in obese children: a retrospective analysis. J Clin Gastroenterol. 2010;44:e253-e255. 31. Petnehazy T, Saxena AK, Ainoedhofer H, Hoellwarth ME, Schalamon J. Single-port appendectomy in obese children: an optimal alternative? Acta Paediatr. 2010;99:1370-1373. 32. Kraft R, Herndon DN, Williams FN, Al-Mousawi AM, Finnerty CC, Jeschke MG. The effect of obesity on adverse outcomes and metabolism in pediatric burn patients. Int J Obes (Lond). 2012;36:485-490. 33. Brown CV, Neville AL, Salim A, Rhee P, Cologne K, Demetriades D. The impact of obesity on severely injured children and adolescents. J Pediatr Surg. 2006;41:88-91. 34. Davies DA, Yanchar NL. Appendicitis in the obese child. J Pediatr Surg. 2007;42:857-861. 35. Linam WM, Margolis PA, Staat MA, et al. Infect Control Hosp Epidemiol. 2009;30:109-116. 36. Cook-Sather SD, Gallagher PR, Kruge LE, et al. Overweight/obesity and gastric fluid characteristics in pediatric day surgery: implications for fasting guidelines and pulmonary aspiration risk. Anesth Analg. 2009;109:727-736. 37. Shine NP, Coates HL, Lannigan FJ, Duncan AW. Adenotonsillar surgery in morbidly obese children: routine elective admission of all patients to the intensive care unit is unnecessary. Anaesth Intensive Care. 2006;34:724-730. 38. Kang JW, Vann WF, Lee JY, Anderson JA. The safety of sedation for overweight/obese children in the dental setting. Pediatr Dent. 2012;34:392-396. 39. Nafiu OO, Reynolds PI, Bamgbade OA, Tremper KK, Welch K, Kasu-Vubu JZ. Childhood body mass index and perioperative complications. Pediatr Anesth. 2007;17:426-430.
40. Garey CL, Laituri CA, Keckler SJ, et al. Laparoscopic cholecystectomy in obese and non-obese children. J Surg Res. 2010;163:299-302. 41. Mantadakis E, Spanaki A, Geromarkaki E, Vassilaki E, Briassoulis G. Near demise of a child with Prader-Willi syndrome during elective orchidopexy. Pediatr Anesth. 2006;16:790-793. 42. Tweedie DJ, Bajaj Y, Ieacho SN, et al. Peri-operative complications after adenotonsillectomy in a UK pediatric tertiary referral centre. Int J Pediatr Otorhinolaryngol. 2012;76:809-815. 43. Kutasy B, Hunziker M, Laxamanadass G, Puri P. Laparoscopic appendectomy is associated with lower morbidity in extremely obese children. Pediatr Surg Int. 2011;27:533-536. 44. Sinha M, Lezine MW, Frechette A, Foster KN. Weighing the pediatric patient during trauma resuscitation and its concordance with estimated weight using Broselow Luten Emergency Tape. Pediatr Emerg Care. 2012;28:544-547. 45. Milne WK, Yasin A, Knight J, Noel D, Lubell R, Filler G. Ontario children have outgrown the Broselow tape. CJEM. 2012;14:25-30. 46. Rosenberg M, Greenberger S, Rawal A, Latimer-Pierson J, Thundiyil J. Comparison of Broselow tape measurements versus physician estimations of pediatric weights. Am J Emerg Med. 2011;29:482-488. 47. Miller JL, Johnson PN, Harrison DL, Hagemann TM. Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight children. Ann Pharmacother. 2010;44:35-42. 48. Moffett BS, Ung M, Bomgaars L. Risk factors for elevated INR values during warfarin therapy in hospitalized pediatric patients. Pediatr Blood Cancer. 2012;58:941-944. 49. Lewis TV, Johnson PN, Nebbia AM, Dunlap M. Increased enoxaparin dosing is required for obese children. Pediatrics. 2011;127:e787-e790. 50. Sulowski C, Doria AS, Langer JC, Man C, Stephens D, Schuh S. Clinical outcomes in obese and normal-weight children undergoing ultrasound for suspected appendicitis. Acad Emerg Med. 2011;18:167-173. 51. Kutasy B, Hunziker M, Laxamanadass G, Puri P. Increased incidence of negative appendectomy in childhood obesity. Pediatr Surg Int. 2010;26:959-962. 52. Kutasy B, Laxamanadass G, Puri P. Is C-reactive protein a reliable test for suspected appendicitis in extremely obese children? Pediatr Surg Int. 2010;26:123-125. 53. Nafiu OO, Burke C, Cowan A, Tutuo N, Maclean S, Tremper KK. Comparing peripheral venous access between obese and normal weight children. Paediatr Anaesth. 2010;20:172-176. 54. Olutoye OA, Yu X, Govindan K, et al. The effect of obesity on the ED95 of propofol for loss of consciousness in children and adolescents. Anesth Analg. 2012;115:147-153. 55. Stein PD, Beemath A, Olson RE. Obesity as a risk factor in venous thromboembolism. Am J Med. 2005;118:978-980. 56. Hanson SJ, Punzalan RC, Arca MJ, et al. Effectiveness of clinical guidelines for deep vein thrombosis p rophylaxis in
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
987
Halvorson et al reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma. 2012;72:1292-1297. 57. Raffini L, Trimarchi T, Beliveau J, Davis D. Thromboprophylaxis in a pediatric hospital: a patientsafety and quality-improvement initiative. Pediatrics. 2011;127:e1326-e1332. 58. Mayes T, Gottschlich MM, Allgeier C, Khoury J, Kagan RJ. Overweight and obesity: overrepresentation in the pediatric reconstructive burn population. J Burn Care Res. 2010;31:423-428.
59. Alselaim N, Malaekah H, Saade M, et al. Does obesity impact the pattern and outcome of trauma in children? J Pediatr Surg. 2012;47:1404-1409. 60. Sleeper EJ, Ariza AJ, Binns HJ. Do hospitalized pediatric patients have weight and blood pressure concerns identified? J Pediatr. 2009;154:213-217. 61. Woo JG, Zeller MH, Wilson K, Inge T. Obesity identified by discharge ICD-9 codes underestimates the true prevalence of obesity in hospitalized children. J Pediatr. 2009;154:327-331.
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Pediatric Obesity and Safety in Inpatient Settings: A Systematic Literature Review Elizabeth E. Halvorson, Megan B. Irby and Joseph A. Skelton CLIN PEDIATR 2014 53: 975 originally published online 6 May 2014 DOI: 10.1177/0009922814533406 The online version of this article can be found at: http://cpj.sagepub.com/content/53/10/975
Published by: http://www.sagepublications.com
Additional services and information for Clinical Pediatrics can be found at: Email Alerts: http://cpj.sagepub.com/cgi/alerts Subscriptions: http://cpj.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Jul 31, 2014 OnlineFirst Version of Record - May 6, 2014 What is This?
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
533406
research-article2014
CPJXXX10.1177/0009922814533406Clinical PediatricsHalvorson et al
Article
Pediatric Obesity and Safety in Inpatient Settings: A Systematic Literature Review
Clinical Pediatrics 2014, Vol. 53(10) 975–987 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814533406 cpj.sagepub.com
Elizabeth E. Halvorson, MD1, Megan B. Irby, MS1,2, and Joseph A. Skelton, MD, MS1,2,3
Abstract Objective. Pediatric obesity affects more than 16% of American children and is associated with worse outcomes in hospitalized patients. A systematic literature review was performed to identify studies of adverse care events affecting obese pediatric patients in the emergency room, operating room, or inpatient wards. Evidence Review. We systematically searched Medline for articles published from 1970 to 2013 regarding obesity and patient safety events in pediatric acute care settings. We determined the study design, number of patients studied, definition and prevalence of obesity, the relevant acute care setting, the specific association with obesity addressed, and the results of each study. Results and Conclusion. Thirty-four studies documented both procedural complications and issues with general hospital care. Most were retrospective and focused on surgery or anesthesia. Obese patients may have increased risk for a variety of adverse events. Further study could improve institutional patient safety guidelines to enhance care for obese children. Keywords pediatric, obesity, safety, inpatient, surgery
Introduction Pediatric obesity is a significant public health concern, as 16.9% of American children are currently obese, representing a tripling since 1980.1 Obese children are at higher risk for several chronic conditions, including diabetes,2 obstructive sleep apnea,3 nonalcoholic fatty liver disease,4 and gallbladder disease,5 both during childhood and into adulthood. Furthermore, obese children may become more ill if they have several common pediatric conditions, including asthma6 and influenza.7,8 One recent review demonstrated a trend toward increased mortality and increased rate of infections in obese patients who require hospitalization,9 and several studies support that obese inpatients have longer hospital length of stay9-13 and higher hospital charges10,13 than their normal-weight counterparts. Patient safety, brought to national attention with the publication of the Institute of Medicine’s To Err is Human14 and Crossing the Quality Chasm,15 focuses on preventable measures that may adversely affect the outcomes discussed above. The Agency for Healthcare Research and Quality has defined a number of pediatricspecific quality indicator events. These focus on procedure-based complications including accidental
punctures, iatrogenic pneumothoraces, hospital-acquired infections, and postoperative complications. A review of discharges from 38 children’s hospitals in the United States revealed that these events can prolong length of stay as long as 23.5 days in the case of postoperative sepsis and may result in up to $337,226 in excess hospital charges.16 Furthermore, obese patients may face issues with general hospital care unrelated to procedures. For example, medication dosing is typically weight-based in children; thus, appropriate dosing and pharmacokinetics for an obese patient may not be evident.17 Although obese children are known to have poor clinical outcomes, it is unclear whether adverse patient-care 1
Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA 2 Brenner FIT Program, Brenner Children’s Hospital, Winston-Salem, NC, USA 3 Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA Corresponding Author: Elizabeth E. Halvorson, Department of Pediatrics, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
976
Clinical Pediatrics 53(10)
events are a contributing factor. This knowledge could change institutional patient safety protocols, many of which do not specifically address obese patients.18,19 In this systematic literature review, we identified studies of patient safety issues in obese children and asked whether obesity contributes to increased mortality, prolonged length of stay, and increased hospital charges. We hypothesize that obese inpatient children and adolescents are at greater risk for adverse patient-care events, which may contribute to overall poorer outcomes and increased medical costs.
Methods We systematically searched Medline (PubMed) from 1970 to April 2013 for English-language manuscripts of children (birth to 18 years old), treated within acute care settings, specifically inpatient hospitalizations, emergency department visits, surgical operations, or other acute inpatient procedures. We focused on studies that identified overweight or obese children as a specific subpopulation in their analysis. Referenced articles of relevance within these studies were also extracted and included. There is no universal definition of patient safety. For this review, we conceptualized patient safety to incorporate issues specific to procedures and general hospital care. For procedural complications, we focused on many of the Agency for Healthcare Research and Quality pediatric-specific quality indicator events, including accidental lacerations or punctures, decubitus ulcers, retained foreign body, iatrogenic pneumothoraces, hospital-acquired infections, and perioperative hemorrhage, respiratory failure, sepsis, and wound dehiscence.16,20 Under general hospital care, we included patient issues related to blood products, environment, equipment or medical devices, falls, laboratory errors, medications, and radiology.21 Terms used for the literature search were pediatric obesity in combination with one of the following terms: safety, acute care, trauma, hospitalization, admission, iatrogenic, falls, thrombosis, infection, screening, pneumothorax, transfusion, foreign body, and errors. Study titles and abstracts were initially reviewed for inclusion criteria, specifically pediatric obesity, any element of patient safety identified above, and patients within the hospital, emergency department, or operating room settings. Studies were excluded if they were not available in English, included only adult patients, were conducted outside of an acute care setting, did not compare an overweight/obese population with a normal-weight population, or were not specific to a patient safety issue identified above. Data extracted from each study included the study design, number of patients studied, definition
and prevalence of obesity, the relevant acute care setting, the specific question or association with obesity addressed, and the results. The primary investigator (EEH) independently screened all titles and abstracts identified in the search, and obtained full texts for articles meeting inclusion criteria or if abstracts lacked sufficient information to determine inclusion. Full-text articles were then reviewed to determine inclusion and were classified based on patient safety topic into one of 2 broad categories: procedural complications and general hospital care. Articles were classified based on the type of study and were grouped based on patient safety classification and study design for analysis.
Results A total of 402 studies met the initial search criteria and were reviewed for inclusion. Applying the criteria noted above narrowed this group to 34 studies, which were included in the final analysis. The search results are displayed in Figure 1. Studies identified possible safety issues associated with obesity across many topics. Articles were reviewed and grouped by general patient safety areas as defined above: procedural complications (n = 22) and general hospital care (n = 12). Overall, most studies (n = 22) were retrospective. Table 1 lists studies that focused on complications from procedures, specifically accidental punctures, decubitus ulcers, retained foreign bodies, thrombosis, iatrogenic pneumothoraces, hospital-acquired infections, and perioperative complications (both airway related and non–airway related). Most studies focused on perioperative complications; several demonstrated increased risk of airway obstruction and oxygen desaturation during sedation.13,22-24 No other perioperative complications were consistently associated with obesity. A few studies suggested increased risk of decubitus ulcers25 and thrombosis25-28 in obese patients. Table 2 lists studies related to safety issues affecting general hospital care. Several articles were relevant to the safety of equipment and medical devices when used in obese children. For example, the Broselow tape (used to estimate weight in emergency settings) frequently underestimated weight in obese children.44-46 Furthermore, a retrospective chart review by Miller et al47 demonstrated a statistically significant increase in dosing errors for overweight patients. Studies focused on anticoagulation reported difficulties in attaining therapeutic drug levels in obese patients.48,49 Additional studies addressed radiologic issues50,51 and the predictive value of C-reactive protein52 in obtaining a diagnosis of appendicitis in obese patients. No studies specifically addressed blood product safety or falls.
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
977
Halvorson et al
Total References Generated 402
Full Texts Reviewed for Inclusion 96
Excluded: Failed to meet Inclusion Criteria 306
Excluded from Analysis 62 1 No menon of obesity 1 Adult only 3 Non-acute 6 No comparison group 11 reviews 40 No relevant safety event
Included in Final Analysis 34
Procedural Complica ons 22 18 Retrospecve 3 Prospecve 1 Case Report
General Safety 12 4 Retrospecve 5 Prospecve 2 Survey 1 Case Report
Figure 1. Decision tree for results of literature review searches.
Few studies assessed clinical outcome following the adverse safety event, and none addressed subsequent mortality or hospital charges. Only 7 of the studies assessed length of stay. A recent review suggests that obese children tend to have longer hospital stays than normal-weight children.9 Some studies support this finding, specifically a report of children undergoing adenotonsillectomy for sleep-disordered breathing,22 in which obese children had a higher rate of perioperative complications. Nafiu et al13 also found that body mass index had a positive correlation with length of stay in patients undergoing adenotonsillectomy. However, no difference in hospital length of stay or rate of perioperative complications was seen between normal-weight, overweight, and obese children in patients undergoing ultrasound for diagnosis of appendicitis50 or laparoscopic cholecystectomy.40
Discussion We performed a systematic literature review to assess the incidence of adverse patient-care events and overall safety in obese children in the acute care setting. Our
goals were to determine if patient safety was compromised for obese children compared with normal-weight children; if patient safety issues contribute to the documented increases in mortality, length of stay, and hospital charges incurred by obese patients; and if specific issues could be identified for inclusion in institutional patient safety protocols. To our knowledge, this is the first literature review targeting the topic of pediatric obesity and patient safety. We found clear evidence that obesity influences patient safety in 4 major fields: medication safety, venous thromboembolism, surgery, and airway management. Several studies addressed issues of medication dosing,47-49 although none assessed the effects of medication over- or underdosing. Since medications are typically dosed based on weight or body surface area, appropriate dosing may be difficult to determine for obese patients. Furthermore, medications may be distributed throughout the body differently based on body composition, thus affecting medication efficacy. Drug pharmacokinetics are frequently altered in obese patients, which may be especially problematic in medications with a narrow therapeutic window.17 Studies
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
978
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Citation/Site
Population Analyzed
BMI >95%; 294 obese, 1020 nonobese
Obesity/Overweight Definition
Hanevold et al,28 database, United States
1314 pediatric trauma Rana et al,25 single center, United States patients
Hospital-acquired infection Petnehazy et al,31 single 94 patients undergoing center, Austria appendectomy
Iatrogenic pneumothorax Harwood et al,30 single 107 children >5 years center, United States old undergoing blind percutaneous liver biopsy
Vu et al,27 database, United States
Findings
Prospective
Retrospective Increased rate of decubitus ulcer complicating injuries to obese patients
Study Design
Perioperative complications, including pneumothorax, following blind percutaneous liver biopsy
Severity of traumatic injury
Outcomes after renal transplant
Retrospective No significant difference in biopsy success or complication rate between obese and nonobese patients
Retrospective Obese patients younger, shorter, and had been on dialysis longer before transplant. Obese children 6-12 years more likely to die than nonobese counterparts. More likely to lose graft due to thrombosis if obese Retrospective Increased rate of venous thromboembolism complicating injuries to obese patients
(continued)
BMI >95%; 29 obese, 65 nonobese Perioperative Retrospective No significant difference in operative complications time between obese and nonobese from single-port patients. One wound healing appendectomy complication in obese group; one postoperative bleeding and one wound infection in nonobese group
Obese BMI >95% (n = 30); nonobese BMI 95%; 294 obese, 1020 nonobese
16 cases of patients diagnosed with pulmonary embolus 1 651 196 hospital admissions included in database 6658 pediatric patients BMI >95%; 649 obese, 6009 following renal transplant nonobese
Tavil et al,29 single center, Turkey
Risk of cerebral venous thrombosis
Severity of traumatic injury
Study Question
Combination of prothrombotic risk factor with underlying condition (including obesity) increased risk of cerebral venous thrombosis No definition, 1 case described as Risk of pulmonary Retrospective One patient with pulmonary embolism obese embolus had obesity associated with operated craniopharyngioma ICD-9 code for obesity as Risk factors for Retrospective Obese patients at higher risk of DVT discharge diagnosis DVT than nonobese
Thrombosis Heller et al,26 database, 149 patients with cerebral No definition, 2 cases described Germany venous thrombosis, ages as obese 0-18 years
Accidental lacerations/punctures Decubitus ulcer 1314 pediatric trauma Rana et al,25 single center, United States patients
Patient Safety Issue
Table 1. Patient Safety Events Related to Procedures.
979
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Davies et al,34 single center, Canada
176 patients undergoing Linam et al,35 single center, United States spinal fusion
Study Question
Study Design
Fung et al,22 single center, Canada 49 obese patients + matched controls undergoing adenotonsillectomy for sleep-disordered breathing
Findings
Morbidly obese BMI >95% Incidence of sepsis Retrospective No significant differences in sepsis, (n = 144); obese BMI 90% to 95% multiple organ failure, or mortality (n = 83); overweight BMI 85% to 90% (n = 50); normal BMI 95% (n = 54); lean Incidence of sepsis Retrospective Increased incidence of sepsis and BMI 2 SD over Length of stay, Retrospective Trend toward increased incidence mean (n = 31); moderately obese incidence of of wound infection in very obese weight >1.5 SD over mean (n = wound infection patients with perforated appendicitis, 25); normal weight (n = 226) but not statistically significant. Longer length of stay in very obese patients 44 case patients who developed Rate of obesity Retrospective Obesity with BMI >95% was significant surgical site infection each with BMI >95% risk factor associated with surgical matched to 3 controls who did in cases versus site infection not controls
Obesity/Overweight Definition
Overweight BMI 90% to 95% or obese BMI >95%; 49 obese, 49 matched nonobese
Incidence of postoperative respiratory complications
(continued)
No effect of BMI on gastric fluid volumes before anesthesia (indirect measure of aspiration risk). Emesis on induction occurred in 8 patients (50% obese, 75% with obstructive sleep apnea), but no aspiration events Retrospective Obesity significantly increases risk of postoperative complications, including major events. Obese children had significantly more upper airway obstruction and longer hospital length of stay
Operative complications—Airway 1000 day surgery patients Lean BMI 25% to 75% (n = 424); Risk of aspiration Prospective Cook-Sather et al,36 single center, United overweight BMI 85% to 95% (n = during anesthesia States 140); obese BMI >95% (n = 133)
282 patients undergoing appendectomy
316 trauma patients Brown et al,33 single center, United States
Population Analyzed
Kraft et al,32 single 592 patients with >30% center, United States body surface area burn
Citation/Site
Patient Safety Issue
Table 1. (continued)
980
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Fung et al,22 single center, Canada 49 obese patients plus matched controls undergoing adenotonsillectomy for sleep-disordered breathing
Operative complications—Other 592 patients with >30% Kraft et al,32 single center, United States body surface area burn
Overweight BMI 90% to 95% or obese BMI >95%; 49 obese, 49 matched nonobese
Overweight BMI >85%, 47% overweight
Findings
Retrospective Most patients had uncomplicated recovery. Some required supplemental oxygen or repositioning, very few required positive-pressure ventilation, none required reintubation Retrospective Weight percentiles higher in children with one or more adverse events, but not statistically significant Retrospective Overweight and obese patients more likely to have difficult airway, upper airway obstruction in the PACU, PACU stay longer than 3 hours, and need for 2 or more antiemetics. No significant difference in rate of unplanned hospital admission Retrospective Higher incidence of intraoperative oxygen desaturation and unexpected overnight hospitalization for obese patients Prospective Obese children had higher prevalence of comorbid conditions, including asthma, diabetes, hypertension, and sleep apnea. Higher incidence of oxygen desaturation, difficult mask ventilation, and airway obstruction
Study Design
(continued)
Incidence of sepsis, Retrospective No significant difference in sepsis, multiple organ multiple organ failure, or mortality failure, and death Incidence of Retrospective Obesity significantly increases risk postoperative of postoperative complications, respiratory including major events. Obese complications children had significantly more upper airway obstruction and longer hospital length of stay
Overweight BMI 85% to 95% (n Incidence of = 875); obese BMI >95% (n = perioperative 1048); normal weight BMI 95%; 31% patients Incidence of Petnehazy et al,31 single 94 patients undergoing Retrospective No significant difference in operative center, Austria single-port obese perioperative time between obese and nonobese appendectomy complications patients. One wound healing complication in obese group; one postoperative bleeding and one wound infection in nonobese group Need for Retrospective 4/20 morbidly obese patients required Tweedie et al,42 single 1735 patients undergoing Morbid obesity (n = 20) center, United tonsillectomy and/or postoperative PICU admission; most also had other Kingdom adenoidectomy PICU admission comorbidities 1383 obese children Extremely obese BMI >2 SD over Efficacy of open Retrospective Laparoscopic surgery in obese children Kutasy et al,43 single center, Ireland who underwent mean; 238 extremely obese, vs laparoscopic associated with significantly shorter appendectomy 1145 nonobese approach operating time, lower complication rate, and lesser postoperative analgesia
312 patients undergoing Garey et al, single center, United States laparoscopic cholecystectomy
40
Citation/Site
Abbreviations: BMI, body mass index; ICD-9; International Classification of Diseases, Ninth Revision; DVT, deep venous thrombosis; ICU, intensive care unit; SD, standard deviation; PACU, pediatric acute care unit; ARDS, acute respiratory distress syndrome.
Patient Safety Issue
Table 1. (continued)
982
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Citation/Site
19/47 survey responses from NACHRI member hospitals
Population Analyzed
Nafiu et al,53 single center, United States Sinha et al,44 single center, United States Milne et al,45 one urban and one rural health center, Canada Rosenberg et al,46 single center, United States
Falls Laboratory Kutasy et al,52 single center, Ireland
Study Design
BMI z scores calculated using CDC guidelines
No definition
947 patients who underwent appendectomy
Findings
Accuracy of weight Prospective estimation using Broselow tape Accuracy of weight Prospective estimation using Broselow tape
Extremely obese BMI Predictive value of >2 SD over mean; 164 C-reactive protein in extremely obese, 783 diagnosis of appendicitis nonobese
Retrospective
(continued)
Obese patients significantly more likely to have negative appendectomy. C-reactive protein more elevated in obese patients with negative appendectomy than nonobese patients with negative appendectomy. Specificity and positive predictive value significantly lower
Broselow tape more accurate than physician estimation for normal-weight but not obese children
Obese children more likely to have failed first attempt at cannulation and to require 2 or more attempts Length-based weight estimation underestimates weight with worst underestimation for largest children Weight estimate correlates with actual weight but underestimates it
Hospitals with a bariatric surgery program seem better-prepared for severely obese patients; 95%; to address airway 45 freestanding severely obese BMI management, drug dosing, children’s >95% or BMI >40 or and equipment needs of hospitals to weight >260 lb obese patients? assess degree of preparation Obese BMI >95%; 47 Ease of peripheral IV access Prospective obese, 56 nonobese in obese patients
Obesity BMI >95%
Obesity/Overweight Definition
372 patients presenting Overweight BMI 85% to Accuracy of weight Prospective to ED (157 95% (n = 39) tape from BMI measures
103 patients undergoing IV cannulation 231 pediatric trauma patients, ages 0-14 years 6361 patients with height and weight measured
Equipment/medical device safety 28/45 survey Porter et al,19 survey, United responses from States freestanding children’s hospitals
Behavior Blood product Environmental safety Young et al,18 survey, United States
Patient Safety Issue
Table 2. Patient Safety Events Related to General Hospital Care.
983
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
Citation/Site
Population Analyzed
Obesity/Overweight Definition
Risk factors for elevated international normalized ratio on warfarin therapy Concern for underdosing enoxaparin for DVT prophylaxis in obese patients Case report
Retrospective
Retrospective
Study Design
263 patients Obese BMI >85%; 76 undergoing obese, 187 nonobese screening ultrasound for suspected appendicitis
1228 patients undergoing appendectomy
Sulowski et al,50 single center, Canada
Kutasy et al,51 single center, Ireland
Does ultrasound for Prospective diagnosis of appendicitis in obese children lead to favorable outcome: (1) nonperforated appendicitis or other diagnosis undergoing appropriate surgical procedure within 24 hours without CT scan or (2) no appendicitis and discharged from ED within 24 hours without CT scan Extremely obese BMI Incidence of negative Retrospective >2 SD over mean, 207 appendectomy in obese extremely obese, 1021 patients nonobese
298 admissions for 184 Obese BMI >95%, 22.5% Moffett et al,48 single center, patients on warfarin obese United States BMI 105.9, 85.7, and 29.9 Lewis et al,49 single 3 cases of obese center, United patients kg/m2, all >95% States
Incidence of medication over- or underdosing in overweight patients
Study Question
Incidence of negative appendectomy significantly higher in obese than nonobese patients. Sensitivity, specificity, and predictive value of ultrasound significantly lower in obese patients
Similar rate of favorable outcomes, rate of hospitalization, median hospital length of stay, rate of return ED visit, and time to surgery. Obese patients more likely to undergo CT scan within 30 days of initial presentation
Statistically significant increase in dosing errors for overweight patients, with underdosing occurring more frequently than overdosing Obesity was an independent variable associated with nonelevated international normalized ratio Three cases of obese pediatric inpatients all required greater than adult maximum doses of enoxaparin to reach therapeutic anti–factor Xa levels
Findings
Abbreviations: NACHRI, National Association of Children’s Hospitals and Related Institutions; BMI, body mass index; IV, intravenous; CDC, Centers for Disease Control and Prevention; ED, emergency department; SD, standard deviation; DVT, deep venous thrombosis; CT, compute dtomography.
Radiology
Medication issues Miller et al,47 single 839 admissions for 699 Overweight BMI >85%, center, United patients admitted to 33% of all admissions States the hospital
Patient Safety Issue
Table 2. (continued)
984
Clinical Pediatrics 53(10)
defining appropriate dosing for specific medications have demonstrated these difficulties. Olutoye et al54 prospectively determined the effective dose of propofol for induction of anesthesia in obese children and found it to be lower (in weight-based dosing) than that for normalweight children. Since obese children may be receiving inappropriate doses of medications, it will be important to determine the incidence of adverse drug events in this population. Similarly, several studies, mostly retrospective database reviews, suggested that obesity may contribute to an increased incidence of thrombosis; however, they also noted that patients who experienced venous thromboembolism typically had other risk factors, such as presence of a central venous catheter, limited mobility, use of oral contraceptives, or coexisting malignancy or fracture.25-29 In adults, obesity is a clear risk factor for venous thromboembolism55 and is frequently included in guidelines for prophylaxis. There is increasing interest in the potential need for prophylaxis in children,56,57 so definitive determination of the risk conferred by obesity will be crucial as these pediatric guidelines are developed. Most studies reviewed here focused on surgery and anesthesia. Two separate studies by Kutasy et al51,52 demonstrated an increased incidence of unnecessary appendectomy in obese children, attributed to the decreased specificity and positive predictive value of C-reactive protein and ultrasound for diagnosis. Researchers also found that certain operative techniques may be more appropriate for obese pediatric patients.31,43 An example is the use of laparoscopic appendectomy, which resulted in shorter operating time, lower complication rate, and less need for postoperative analgesia in pediatric obese patients.43 Multiple studies raised concerns about obese patients undergoing sedation or general anesthesia. Many demonstrated increased incidence of upper airway obstruction13,22,24 and oxygen desaturation.23,24,58 In the study by Shine et al,37 however, most obese children had an uneventful recovery following anesthesia for adenotonsillectomy. Data on the incidence of wound infections and sepsis are mixed; several studies33-35 reported trends toward increased incidence in obese patients compared with nonobese, while other studies found no difference between the populations. The incidence of other perioperative complications, such as wound dehiscence or postoperative bleeding, was not higher among obese pediatric patients compared with nonobese.31,32,40 However, small sample sizes and retrospective study design limit the interpretation of these reports. For many other types of patient safety events, no studies have been done to assess obesity as a potential
contributing factor. Although one study indicated that the first attempt at peripheral intravenous cannulation was more likely to fail in obese children,53 no studies specifically assessed the number of accidental punctures or lacerations in such patients. Additionally, no studies examined the risk of falls in obese inpatients. There is evidence that obese children sustain increased extremity fractures25 and rib and pelvic injuries59 following trauma compared with nonobese patients, so falls in this population could lead to a worse outcome. Use of hospital equipment not optimized for obese patients could also contribute to increased risk of falls in this population. Several studies assessed the need for enhanced hospital preparation when treating obese pediatric patients. In 2 survey-based studies, only 37% of children’s hospitals have a policy in place to identify and treat overweight or obese patients,18 and 95%, a measure which fails to account for actual body composition. Many articles were single-center reports, which may limit the generalizability of the results to broader and more diverse populations. Furthermore, most studies were retrospective and therefore could not address causative effects of obesity relative to patient safety events. Some studies did identify areas in which pediatric obesity affects issues of patient safety. These areas are disparate and often very specific, such as the use of Broselow tape for estimating weights in acute situations44-46 or the efficacy of different diagnostic measures for appendicitis.50-52 However, in many areas there is only preliminary or theoretical evidence that obesity
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
985
Halvorson et al may contribute to errors, as in medication dosing. It remains unknown whether patient safety errors contribute to the increased mortality, prolonged length of stay, and greater hospital charges incurred by obese pediatric patients. Further studies may help influence the development of institutional policies and protocols to improve the safety of obese pediatric inpatients. Acknowledgments The authors would like to thank Karen Klein (Translational Science Institute, Wake Forest School of Medicine) for providing helpful edits to this article.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by a grant from NICHD/NIH Mentored Patient-Oriented Research Career Development Award K23 HD061597 (JAS).
References 1. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303:242-249. 2. Dabalea D, Bell RA, D’Agostino RB Jr, et al. Incidence of diabetes in youth in the United States. JAMA. 2007;297:2716-2724. 3. Gozal D, Kheirandish-Gozal L. Childhood obesity and sleep: relatives, partners, or both? A critical perspective on the evidence. Ann N Y Acad Sci. 2012;1264:135-141. 4. Giorgio V, Prono F, Graziano F, Nobili V. Pediatric nonalcoholic fatty liver disease: old and new concepts on development, progression, metabolic insight and potential treatment targets. BMC Pediatr. 2013;13:40. 5. Mehta S, Lopez ME, Chumpitazi BP, Mazziotti MV, Brandt ML, Fishman DS. Clinical characteristics and risk factors for symptomatic pediatric gallbladder disease. Pediatrics. 2012;129:e82-e88. 6. Carroll CL, Bhandari A, Zucker AR, Schramm CM. Childhood obesity increases duration of therapy during severe asthma exacerbations. Pediatr Crit Care Med. 2006;7:527-531. 7. Chen WH, Lu CY, Shao PL, et al. Risk factors of severe novel influenza A(H1N1) infections in hospitalized children. J Formos Med Assoc. 2012;111:421-426. 8. Plessa E, Diakakis P, Gardelis J, Thirios A, Koletsi P, Falagas ME. Clinical features, risk factors, and complications among pediatric patients with pandemic influenza A (H1N1). Clin Pediatr (Phila). 2010;49:777-781.
9. Bechard LJ, Rothpletz-Puglia P, Touger-Decker R, Duggan C, Mehta NM. Influence of obesity on clinical outcomes in hospitalized children: a systematic review. JAMA Pediatr. 2013;167:476-482. 10. Woolford SJ, Gebremariam A, Clark SJ, Davis MM. Persistent gap of incremental charges for obesity as a secondary diagnosis in common pediatric hospitalizations. J Hosp Med. 2009;4:149-156. 11. Woolford SJ, Gebremariam A, Clark SJ, Davis MM. Incremental hospital charges associated with obesity as a secondary diagnosis in children. Obesity (Silver Spring). 2007;15:1895-1901. 12. O’Connor J, Youde LS, Allen JR, Baur LA. Obesity and under-nutrition in a tertiary paediatric hospital. J Paediatr Child Health. 2004;40:299-304. 13. Nafiu OO, Chimbira WT, Woolford SJ, Tremper KK, Reynolds PI, Green GE. Does high BMI influence hospital charges in children undergoing adenotonsillectomy? Obesity (Silver Spring). 2008;16:1667-1671. 14. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 1999. 15. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 16. Kronman MP, Hall M, Slonim AD, Shah SS. Charges and lengths of stay attributable to adverse patient-care events using pediatric-specific quality indicators: a multicenter study of freestanding children’s hospitals. Pediatrics. 2008;121:e1653-e1659. 17. Cheymol G. Effects of obesity on pharmacokinet ics implications for drug therapy. Clin Pharmacokinet. 2000;39:215-231. 18. Young KL, Demeule M, Stuhlsatz K, et al. Identification and treatment of obesity as a standard of care for all patients in children’s hospitals. Pediatrics. 2011;128(suppl 2): S47-S50. 19. Porter RM, Thrasher J, Krebs NF. Implementing a pediatric obesity care guideline in a freestanding children’s hospital to improve child safety and hospital preparedness. J Pediatr Nurs. 2012;27:707-714. 20. Dynan L, Goudie A, Smith RB, Fairbrother G, Simpson LA. Differences in quality of care among non-safetynet, safety-net, and children’s hospitals. Pediatrics. 2013;131:304-311. 21. Chamberlain JM, Shaw KN, Lillis KA, et al; Pediatric Emergency Care Applied Research Network. Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network. Pediatr Emerg Care. 2013;29:125-130. 22. Fung E, Cave D, Witmans M, Gan K, El-Hakim H. Postoperative respiratory complications and recovery in obese children following adenotonsillectomy for sleepdisordered breathing: a case-control study. Otolaryngol Head Neck Surg. 2010;142:898-905. 23. Setzer N, Saade E. Childhood obesity and anesthetic morbidity. Paediatr Anaesth. 2007;17:321-326.
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
986
Clinical Pediatrics 53(10)
24. Tait AR, Voepel-Lewis T, Burke C, Kostrzewa A, Lewis I. Incidence and risk factors for perioperative adverse respiratory events in children who are obese. Anesthesiology. 2008;108:375-380. 25. Rana AR, Michalsky MP, Teich S, Groner JI, Caniano DA, Schuster DP. Childhood obesity: a risk factor for injuries observed at a level-1 trauma center. J Pediatr Surg. 2009;44:1601-1605. 26. Heller C, Heinecke A, Junker R, et al; Childhood Stroke Study Group. Cerebral venous thrombosis in children: a multifactorial origin. Circulation. 2003;108:1362-1367. 27. Vu LT, Nobuhara KK, Lee H, Farmer DL. Determination of risk factors for deep venous thrombosis in hospitalized children. J Pediatr Surg. 2008;43:1095-1099. 28. Hanevold CD, Ho PL, Talley L, Mitsnefes MM. Obesity and renal transplant outcome: a report of the North American Pediatric Renal Transplant Cooperative Study. Pediatrics. 2005;115:352-356. 29. Tavil B, Kuskonmaz B, Kiper N, Cetin M, Gumruk F, Gurgey A. Pulmonary thromboembolism in childhood: a single-center experience from Turkey. Heart Lung. 2009;38:56-65. 30. Harwood J, Bishop P, Liu H, Nowick M. Safety of blind percutaneous liver biopsy in obese children: a retrospective analysis. J Clin Gastroenterol. 2010;44:e253-e255. 31. Petnehazy T, Saxena AK, Ainoedhofer H, Hoellwarth ME, Schalamon J. Single-port appendectomy in obese children: an optimal alternative? Acta Paediatr. 2010;99:1370-1373. 32. Kraft R, Herndon DN, Williams FN, Al-Mousawi AM, Finnerty CC, Jeschke MG. The effect of obesity on adverse outcomes and metabolism in pediatric burn patients. Int J Obes (Lond). 2012;36:485-490. 33. Brown CV, Neville AL, Salim A, Rhee P, Cologne K, Demetriades D. The impact of obesity on severely injured children and adolescents. J Pediatr Surg. 2006;41:88-91. 34. Davies DA, Yanchar NL. Appendicitis in the obese child. J Pediatr Surg. 2007;42:857-861. 35. Linam WM, Margolis PA, Staat MA, et al. Infect Control Hosp Epidemiol. 2009;30:109-116. 36. Cook-Sather SD, Gallagher PR, Kruge LE, et al. Overweight/obesity and gastric fluid characteristics in pediatric day surgery: implications for fasting guidelines and pulmonary aspiration risk. Anesth Analg. 2009;109:727-736. 37. Shine NP, Coates HL, Lannigan FJ, Duncan AW. Adenotonsillar surgery in morbidly obese children: routine elective admission of all patients to the intensive care unit is unnecessary. Anaesth Intensive Care. 2006;34:724-730. 38. Kang JW, Vann WF, Lee JY, Anderson JA. The safety of sedation for overweight/obese children in the dental setting. Pediatr Dent. 2012;34:392-396. 39. Nafiu OO, Reynolds PI, Bamgbade OA, Tremper KK, Welch K, Kasu-Vubu JZ. Childhood body mass index and perioperative complications. Pediatr Anesth. 2007;17:426-430.
40. Garey CL, Laituri CA, Keckler SJ, et al. Laparoscopic cholecystectomy in obese and non-obese children. J Surg Res. 2010;163:299-302. 41. Mantadakis E, Spanaki A, Geromarkaki E, Vassilaki E, Briassoulis G. Near demise of a child with Prader-Willi syndrome during elective orchidopexy. Pediatr Anesth. 2006;16:790-793. 42. Tweedie DJ, Bajaj Y, Ieacho SN, et al. Peri-operative complications after adenotonsillectomy in a UK pediatric tertiary referral centre. Int J Pediatr Otorhinolaryngol. 2012;76:809-815. 43. Kutasy B, Hunziker M, Laxamanadass G, Puri P. Laparoscopic appendectomy is associated with lower morbidity in extremely obese children. Pediatr Surg Int. 2011;27:533-536. 44. Sinha M, Lezine MW, Frechette A, Foster KN. Weighing the pediatric patient during trauma resuscitation and its concordance with estimated weight using Broselow Luten Emergency Tape. Pediatr Emerg Care. 2012;28:544-547. 45. Milne WK, Yasin A, Knight J, Noel D, Lubell R, Filler G. Ontario children have outgrown the Broselow tape. CJEM. 2012;14:25-30. 46. Rosenberg M, Greenberger S, Rawal A, Latimer-Pierson J, Thundiyil J. Comparison of Broselow tape measurements versus physician estimations of pediatric weights. Am J Emerg Med. 2011;29:482-488. 47. Miller JL, Johnson PN, Harrison DL, Hagemann TM. Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight children. Ann Pharmacother. 2010;44:35-42. 48. Moffett BS, Ung M, Bomgaars L. Risk factors for elevated INR values during warfarin therapy in hospitalized pediatric patients. Pediatr Blood Cancer. 2012;58:941-944. 49. Lewis TV, Johnson PN, Nebbia AM, Dunlap M. Increased enoxaparin dosing is required for obese children. Pediatrics. 2011;127:e787-e790. 50. Sulowski C, Doria AS, Langer JC, Man C, Stephens D, Schuh S. Clinical outcomes in obese and normal-weight children undergoing ultrasound for suspected appendicitis. Acad Emerg Med. 2011;18:167-173. 51. Kutasy B, Hunziker M, Laxamanadass G, Puri P. Increased incidence of negative appendectomy in childhood obesity. Pediatr Surg Int. 2010;26:959-962. 52. Kutasy B, Laxamanadass G, Puri P. Is C-reactive protein a reliable test for suspected appendicitis in extremely obese children? Pediatr Surg Int. 2010;26:123-125. 53. Nafiu OO, Burke C, Cowan A, Tutuo N, Maclean S, Tremper KK. Comparing peripheral venous access between obese and normal weight children. Paediatr Anaesth. 2010;20:172-176. 54. Olutoye OA, Yu X, Govindan K, et al. The effect of obesity on the ED95 of propofol for loss of consciousness in children and adolescents. Anesth Analg. 2012;115:147-153. 55. Stein PD, Beemath A, Olson RE. Obesity as a risk factor in venous thromboembolism. Am J Med. 2005;118:978-980. 56. Hanson SJ, Punzalan RC, Arca MJ, et al. Effectiveness of clinical guidelines for deep vein thrombosis p rophylaxis in
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
987
Halvorson et al reducing the incidence of venous thromboembolism in critically ill children after trauma. J Trauma. 2012;72:1292-1297. 57. Raffini L, Trimarchi T, Beliveau J, Davis D. Thromboprophylaxis in a pediatric hospital: a patientsafety and quality-improvement initiative. Pediatrics. 2011;127:e1326-e1332. 58. Mayes T, Gottschlich MM, Allgeier C, Khoury J, Kagan RJ. Overweight and obesity: overrepresentation in the pediatric reconstructive burn population. J Burn Care Res. 2010;31:423-428.
59. Alselaim N, Malaekah H, Saade M, et al. Does obesity impact the pattern and outcome of trauma in children? J Pediatr Surg. 2012;47:1404-1409. 60. Sleeper EJ, Ariza AJ, Binns HJ. Do hospitalized pediatric patients have weight and blood pressure concerns identified? J Pediatr. 2009;154:213-217. 61. Woo JG, Zeller MH, Wilson K, Inge T. Obesity identified by discharge ICD-9 codes underestimates the true prevalence of obesity in hospitalized children. J Pediatr. 2009;154:327-331.
Downloaded from cpj.sagepub.com at GEORGIAN COURT UNIV on October 16, 2014
