Category: Oral Presentations

O7

DECISION-MAKING AND MULTIDISCIPLINARY TEAM APPROACH FOR COMPLEX AIRWAY MANAGEMENT IN MORQUIO A SYNDROME: EXPERIENCE FROM A NATIONAL REFERRAL SERVICE

J. J. Kenth¹, E. Maughan², S. Wilkinson¹, M. de Kruijf¹, S. Jones¹, C. Butler², I. A. Bruce¹, R. Hewitt², R. Nandi²

¹The Royal Manchester Children's Hospital, UK

²Great Ormond Street Hospital for Children, London, UK

Background/Context

Mucopolysaccharidosis type IVA (MPS IVA or Morquio A Syndrome) is rare lysosomal storage disease associated with progressive, multi-level central airway obstruction due to tracheomalacia, stenosis, and tortuosity.  In severe phenotypes, disease progression culminates in near fatal, airway obstructions, which is the leading cause of death in this cohort [1,2].  Traditional management strategies have been palliative, focusing on symptom relief through non-invasive ventilation (NIV). We aimed to explore the critical role of multidisciplinary team (MDT) decision-making for a novel surgical approach (tracheal resection combined with partial upper manubriectomy) to ameliorate critical airway obstruction in children with MPS IVA [3].

Problem

Patients who progress to critical airway obstruction despite enzyme-replacement-therapy (ERT) lack definitive treatment options, with palliative care being the primary approach. This gap necessitates a novel surgical solution to manage the profound multi-level airway disease and improve quality of life.

Strategy for Change

In a collaborative effort to address near fatal airway obstruction in Morquio Syndrome, Royal Manchester Children's Hospital (RMCH), a leading European centre for metabolic disorders, partnered with Great Ormond Street Hospital (GOSH), home to the national tracheal service. A MDT approach was initiated to develop a referral-to-surgery pathway. This involved setting up a framework for pre-procedural planning, patient selection, and decision-making, leveraging the combined expertise of RMCH and GOSH. The strategy sought to refine the identification of surgical candidates and streamline the process from referral to surgery, optimising the timing for intervention

Measure of Improvement

The effectiveness of the new pathway was evaluated by measuring the referral-to-surgery time (4-6motnhs), postoperative improvements in respiratory function through spirometry, and enhanced quality of life via PedsQL(v4) questionnaires. Improvements were also sought in the consistency of MDT decision-making and the clarity of communication with referring centres and patients.

Lessons Learnt

The initiative demonstrated the critical importance of a centralised expertise and the benefits of a collaborative MDT approach. The robust referral pathway facilitated the surgical management of nine patients across the UK, with significant improvements noted postoperatively, validating the effectiveness of the strategy.

Message for Others

The centralised approach and shared decision making serve as a model for the management of rare diseases requiring highly specialised care. This QI project illustrates how pooling resources and knowledge within a national framework can lead to better patient outcomes and serve as a guide for similar high-risk interventions in other rare diseases.

Conclusion

This QI initiative underscores the value of a national referral pathway and MDT approach in managing complex airway diseases in Morquio A Syndrome. The collaborative efforts between RMCH and GOSH have not only improved patient outcomes but have also set the groundwork for the management of complex medical conditions, promoting a model that can be replicated for other rare diseases.

References:

1. Broomfield A, Kenth J, Bruce IA, Tan HL, Wilkinson S. Respiratory complications of metabolic disease in the paediatric population: A review of presentation, diagnosis and therapeutic options. Paediatric Respiratory Reviews. 2019 Nov;32:55–65.
2. Kenth JJ, Thompson G, Fullwood C, Wilkinson S, Jones S, Bruce IA. The characterisation of pulmonary function in patients with mucopolysaccharidoses IVA: A longitudinal analysis. Mol Genet Metab Rep. 2019 Sep;20:100487.
3. Frauenfelder C, Maughan E, Kenth J, Nandi R, Jones S, Walker R, et al. Tracheal Resection for Critical Airway Obstruction in Morquio A Syndrome. Case Reports in Pediatrics. 2023 May 3;2023:e7976780.

O6

PAEDIATRIC REGIONAL ANAESTHESIA SCANNING CLUB AT THE ROYAL LONDON HOSPITAL

R. Carrington, V. Jenkins, M. Roberts

The Royal London Hospital, London, UK

Introduction and Aims

Regional anaesthesia is an exciting and rapidly developing branch of our specialty. It conveys numerous benefits in the paediatric population including improved early postoperative pain scores and a reduction in opioid analgesia(1). This, combined with evidence of a low incidence of complications make regional anaesthesia a fundamental part of modern paediatric anaesthetic practice(2).

Inspired by the release of the Paediatric Plan A Blocks from RA-UK(3), and enthusiasm from the paediatric anaesthesia department at The Royal London Hospital, we decided to initiate a Paediatric Scanning Club for both consultants and trainees to attend.

We aimed to provide:

1. A concise weekly educational session to cover block indications and relevant anatomy.
2. An opportunity to increase hands-on ultrasound scanning experience and identification of the appropriate sonoanatomy.
3. Discussion opportunity around the differences between the paediatric and adult block, including dosing of local anaesthetic.

Methods

In 2023, we designed and implemented a 7-week programme covering common blocks used in paediatrics including amongst others: femoral, popliteal, axillary and rectus sheath blocks.

Each session was lead by a Stage 2+ trainee on their paediatric anaesthesia placement and supervised by a paediatric consultant anaesthetist proficient in the block of the week.

The trainee leading the session prepared a short presentation including the indications, anatomy, patient positioning, sonoanatomy, recommended local anaesthetic dose and a short video of the block being performed. Following this, there was an opportunity to practise identifying the sonoanatomy on volunteers, and practise needling using jelly containing hidden targets.

We distributed a survey to collect feedback after the 7-week programme.

Results

We received responses from both trainees (67%) and consultants (33%) with 75% of total trainees on the rotation completing the survey (6/8).

• 100% of respondents thought that the Scanning Club sessions they attended improved their theoretical knowledge of performing the relevant block in paediatric patients.
• For every block covered, following the attendance of the scanning club session, more attendees felt confident to perform that paediatric block independently (with a supervisor in the room).
• Suggestions for improvement included: Initiating a changeover time half-way through the session for consultants and trainees who were paired up in theatres to swap over allowing both to attend, and exploring the possibility of scanning practice on paediatric volunteers.

Discussion

This simple format trainee-led teaching session has been positively received by both consultants and trainees and could be easily replicated in other hospitals. The programme has now been repeated three times at RLH, following the three-monthly trainee rotation, with the organisers acting on feedback to make improvements each time. Specific aspects that people have consistently enjoyed include the “small group, focused teaching and regular practice” and that it is a “great opportunity to revise common blocks used in paediatric anaesthesia”.

References:

1. P.-A. Lönnqvist, N. S. Morton, Postoperative analgesia in infants and children, BJA: British Journal of Anaesthesia, Volume 95, Issue 1, July 2005, Pages 59–68
2. Polaner DM, Taenzer AH, Walker BJ, Bosenberg A, Krane EJ, Suresh S, Wolf C, Martin LD. Pediatric Regional Anesthesia Network (PRAN): a multi-institutional study of the use and incidence of complications of pediatric regional anesthesia. Anesthesia & Analgesia. Dec 2012 Dec;115(6):1353-64.
3. RA-UK 2023, Paeds Plan A Posters, https://ra-uk.org/index.php/plan-a-blocks-home/plan-a-paeds/pads-plan-a-posters.html

 

O5

THE EFFECTS OF DEXMEDETOMIDINE ON INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING MODALITIES DURING CORRECTIVE SCOLIOSIS SURGERY IN PEDIATRIC PATIENTS: A SYSTEMATIC REVIEW

A.A. A. M. M. Alkhatip^1,2, K. E. Mills³, O. Hogue⁴, A. Sallam⁵, M. K. Hamza⁶, E. Farag², H. M. Yassin⁷, M.  Wagih⁶, A. M. I. Ahmed⁸, M. H. Helmy⁶, M. Elayashy⁶

¹Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, UK

²Department of Anaesthesia, Faculty of Medicine, Beni Suef University, Beni Suef, Egypt

³Faculty of Science and Technology, University of Canberra, Canberra, Australia

⁴Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA

⁵Department of Anaesthesia, Tallaght University Hospital, Dublin, Ireland

⁶Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt

⁷Department of Anaesthesia, Faculty of Medicine, Fayoum University, Fayoum, Egypt

⁸Department of Anaesthesia, Addenbrooke Hospital, Cambridge University Hospitals, Cambridge, UK

 

Background:

During scoliosis surgery, motor evoked potentials (MEP), and somatosensory evoked potentials (SSEP) have been reported to be affected by the use of higher doses of anesthetic agents. Dexmedetomidine, a sympatholytic agent, an alpha-2 receptor agonist, has been used as an adjunctive agent to lower anesthetic dose. However, there is conflicting evidence regarding the effects of dexmedetomidine on the intraoperative neurophysiological monitoring of MEP and SSEP during surgery, particularly among pediatric patients.

Objectives:

This systematic review aimed to determine whether, during spinal fusion surgery in pediatric patients with scoliosis, dexmedetomidine alters MEP amplitude or SSEP latency and amplitude and, if so, whether different doses of dexmedetomidine display different effects (PROSPERO registration number CRD42022300562).

Methods:

We searched PubMed, Scopus, and Cochrane Library on January 1, 2022 and included randomized controlled trials, observational cohort and case-control studies and case series investigating dexmedetomidine in the population of interest and comparing against a standardized anesthesia regimen without dexmedetomidine or comparing multiple doses of dexmedetomidine. Animal and in vitro studies and conference abstracts were excluded.

 

Results:

We found substantial heterogeneity in the risk of bias (per Cochrane-preferred tools) of the included articles (n = 5); results are summarized without meta-analysis. Articles with the lowest risk of bias indicated that dexmedetomidine was associated with MEP loss and that higher doses of dexmedetomidine increased risk. In contrast, articles reporting no association between dexmedetomidine and MEP loss suffered from higher risk of bias, including suspected or confirmed problems with confounding, outcome measurement, participant selection, results reporting, and lack of statistical transparency and power.

Conclusion:

Given the limitations of the studies available in the literature, it would be advisable to conduct rigorous randomized controlled trials with larger sample sizes to assess the effects of dexmedetomidine use of in scoliosis surgery in pediatric patients.

References:

Abdelaal Ahmed Mahmoud Metwally Alkhatip A, Mills KE, Hogue O, Sallam A, Hamza MK, Farag E, Yassin HM, Wagih M, Ahmed AMI, Helmy MH, Elayashy M. The effects of dexmedetomidine on intraoperative neurophysiologic monitoring modalities during corrective scoliosis surgery in pediatric patients: A systematic review. Paediatr Anaesth. 2024 Feb;34(2):112-120. doi: 10.1111/pan.14795. Epub 2023 Nov 5. PMID: 37927199.

5719461401596. The article is published in Pediatric Anesthesia Journal. The Authors were licensed to present the abstract at the APAGBI 2024 Annual Scientific Meeting. License Number: 5719461401596. License date: Jan 31, 2024. Licensed Content Publisher: John Wiley and Sons

O4

IMPROVING OUTCOMES IN UNILATERAL PELVIC OSTEOTOMY IN CHILDREN AND YOUNG PEOPLE: THE IMPACT OF CONTINUOUS QUADRATUS LUMBORUM CATHETER TECHNIQUE IN AN EPIDURAL LED SERVICE

E. Robinson, J. Keough, I. Okonkwo, S. Roberts, E. Kehoe

Alder Hey Children's Hospital, Liverpool, UK

Background

At Alder Hey Children’s Hospital, lumbar epidural (LE) has been the gold standard regional technique for unilateral pelvic and proximal femoral osteotomy (UPAPFO).  These patients are discharged to Level 1+ ward beds and have high nursing requirements.  Complications such as hypotension, motor blockade, and urinary retention make LEs a less desirable option 1, particularly in patient groups with frailty.  LE use can also be limited by coagulopathy, previous spinal surgery, etc 2.

Problem

There is a paucity of paediatric data, but adult literature suggests that quadratus lumborum blocks (QLB) confer reduced opioid consumption, pain score, length of stay (LOS) and other complications (hypotension, motor weakness, retention etc.) in hip arthroplasty and arthroscopy 3&4  Quadratus lumborum catheters (QLC) might therefore benefit our UPAPFO patients.

Strategy

We used the Plan-Do-Study-Act model to embed QLC use into routine practice alongside a multimodal analgesic regimen in patients undergoing UPAPFO.  We delivered a departmental training programme for QLB and QLC including lectures, practical workshops and real-time clinical support. Patient outcome data and clinical experiences of the acute pain team were presented to the department. Recommendations are ongoing.

Measure of improvement

Between January 2021 and July 2023, 48 patients aged 1-17 years underwent UPAPFO utilising LE (n=31(65%)) or QL catheter (n=17(35%)).  QLC and LE patients had similar demographics (p>0.5:age,gender,weight,ASA). Anaesthetic, perioperative analgesia and outcome data (pain scores, complications and LOS) were recorded.  Audit ID. 6679.  Data analysis with GraphPad.

Learning

This QI-project suggests that QLC combined with multimodal analgesia conferred a similar quality of comfort to LE in our patients.  Total pain scores were similar in QLC and LE groups on day 1 (Median(IQR)=6(1.5-16.5)vs6(3.0-17.0);p>0.5;95%CI-5.0-5.0) and day 2 (Median(IQR)=7(1.5-20.0)vs11(2.0-21.0);p>0.5;95%CI -5.0-9.0);  QLC patients experienced fewer complications (5.8%vs32.6%;p>0.05;95%CI0.01-1.07) and shorter LOS (Median(IQR)=5(4.0-6.0)days vs 6(5.0-8.0) days; p=0.0256;95%CI 0.0-2.0).  One child converted to QLC following a dural tap during LE placement.

 

Ongoing Outcomes

Agreed UPAPFO pathway with QLC

Evaluation of single shot QLB in simpler osteotomy groups e.g. Salter’s Osteotomy

Expansion of local QLC database to national multicentre database

MDT collaboration to improve recording of outcome measures e.g. physio milestones

Evaluating feasibility of Randomised Controlled Trial

Message

QLC presents an alternative and effective analgesic option in children and young people undergoing UPAPFO with comparable analgesia to LE and possibly reduced complications. Formal study of this novel technique is required.

References:

1. Walker B, Long J. Complications in Pediatric Regional Anesthesia: An Analysis of More than 100,000 Blocks from the Pediatric Regional Anesthesia Network. Anesthesiology. 2018. 129(1), 721-732.
2. Cook TM, Counsell D, Wildsmith JA. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists (NAP3). BJA. 2009. 102(2), 179-190.
3. Huda A, Minhas R. Quadratus Lumborum Block Reduces Postoperative Pain Scores and Opioids Consumption in Total Hip Arthroplasty: A Meta- Analysis. Cureus. 2022. 14(2), e22287.
4. Blackwell RE, Kushelev M. A Comparative Analysis of the Quadratus Lumborum Block Versus Femoral Nerve and Fascia Iliaca Blocks in Hip Arthroscopy. Arthrosc Sports Med Rehabil. 2020. 3(1), 7-13.

O3

PINEAPPLE: PaedIatric caNcellation ratEs And PerioPerative clinicaL Evaluation

C. L. Riley¹, T. Bennett², H. Lewis³

¹Sheffield Children's Hospital, Barnsley, UK

²University Hospital Southampton, UK

³Evelina Children's Hospital, London, UK

Introduction and aims

Paediatric pre-operative assessment (P-POA) is an emerging field with the potential to improve outcomes from paediatric surgery.

Best practice P-POA standards are published (1) and it is recommended that “children undergoing anaesthesia should be offered a preadmission pre-assessment service” (2).

PINEAPPLE is a multicentre, prospective observational cohort study.

The primary aims were to:

-           establish the proportion of children 16 years old and under seen in P-POA clinic prior to an elective procedure under general anaesthetic (GA)

-           establish the format of that pre-assessment

The secondary aims were to:

-           establish the on the day cancellation rate for children presenting for surgery and reason for cancellation

-           establish the incidence and impact of anxiety

Methods 

Invitations were sent to members of the Paediatric Anaesthetic Trainee Research Network (PATRN) and the Association of Paediatric Anaesthetists of Great Britain and Ireland (APAGBI). 98 hospitals enrolled and registered the study with their local governance team. The HRA tool determined that this study is a nationally coordinated, locally conducted audit therefore ethical approval and patient consent were not required.

Data collection

Recruitment occurred prospectively between April and June 2023 over a 14-day period. All patients ≤ 16 years of age undergoing an elective procedure under GA were included. The anaesthetist for each list completed a case report form for each patient which was anonymised and uploaded to the electronic database.

Each centre also completed a questionnaire about their delivery of P-POA.

 

Exclusion criteria

Children undergoing emergency or repeated procedures under GA were excluded from the study. Sedation or local anaesthetic cases were also excluded.

Results

The survey found that 80/98 centres (82%) have a P-POA service; 84% of those were nurse-led.

7286 cases were recorded. 4390 patients (59%) had P-POA, most commonly by telephone appointment.  3375 (76%) of those pre-assessed did not need anaesthetic consultant involvement. When this was needed, 503 cases (49%) were resolved with notes review only.

In children seen in P-POA, 15% had management altered; this was most commonly a clinical decision such as bed allocation.

There was no significant difference in on-the-day cancellations between children who had and had not been seen in P-POA; the cancellation rate for each was ~4%. However, a child has a 9% chance of a change on the day without POA (i.e. not proceeding as planned). This reduces to 7% with POA (p<0.05).

Anxiety was an issue preoperatively in 17% of children having an anaesthetic.  This was reduced to 12% if the child had POA (p<0.05).

Discussion and Conclusion

Most UK hospitals offer some form of paediatric pre-operative assessment. This study suggests that this is likely to improve theatre efficiency as well as patient experience and perioperative anxiety. Further statistical analysis of these data are ongoing.

References

1. APAGBI Best Practice Pre-assessment Standards in Children https://www.apagbi.org.uk/sites/default/files/2022-05/Best%20Practice_Pre-assessment%20standards%20in%20Children%20%202022%20-%20Published.pdf Accessed 30/01/2024
2. Royal College of Anaesthetists Guidelines for the Provision of Anaesthetic Services (GPAS) Chapter 10: Guidelines for the Provision of Paediatric Anaesthesia Services 2024 https://www.rcoa.ac.uk/gpas/chapter-10 Accessed 30/01/2024

O2

CAN AN ANAESTHETIC PREOPERATIVE EXCESS WEIGHT PATHWAY IMPROVE OUTCOMES FOR CHILDREN LIVING WITH SEVERE OBESITY?

Z. A. Burton, N. Aswani, L. Cronin, J. Reynolds, N. Marshall, V. Hodgetts

Sheffield Children's NHS Foundation Trust, UK

Background

In 2019 1 in 4 UK children undergoing general anaesthesia were living with overweight and obesity (OAO)(1), figures exacerbated by Covid-19. Childhood obesity leads to a five-fold increased likelihood of adulthood obesity, associated chronic conditions and reduced life expectancy(2). The current estimated UK cost of OAO is £98 billion. Lifestyle interventions can help reduce this burden.

Problem

Children with OAO undergo more surgical procedures, have increased anaesthetic risk and poorer perioperative outcomes. Nationally, there is no robust preoperative screening process to risk-assess or consent for obesity related outcomes, representing a missed opportunity for both risk reduction and health promotion(1).

Strategy for change

In March 2021 a weekly preoperative excess weight clinic was initiated at Sheffield Children’s Hospital for severely obese children (>99.6th BMI centile), involving face-to-face appointments with an anaesthetic consultant trained in motivational interviewing. Anaesthetic risk and comorbidities were evaluated, and individualised age-appropriate lifestyle goals agreed, tailored to biopsychosocial needs. Appropriate referrals were made to paediatricians, Tier 2 programmes and an Exercise and Physical Activity Therapist.

Since 2021, major iterative improvements included: Relocation to the Advanced Wellbeing Research Centre with gym access; Sleep Nurse Specialist referral pathway; close collaborative working and referral to Tier 3 clinics; introducing an app-based digital patient information repository, national guidance on consent and risk discussions(3), Nurse Practitioner-led excess weight clinics and a combined oral health promotion clinic.

Measure of improvement

The natural trajectory is for severely obese children to continue gaining weight into adulthood. Significant improvement in body composition and cardiometabolic risk are evident following BMI standard deviation score (BMI SDS) reductions >0.25, with greater benefits >0.5 BMI SDS(4). The clinic database includes 304 children (41.1% female; mean age 10.4 years, SD 4.01), of which 173 (56.9%) have undergone surgery. 72.3% (n=125) reduced their BMI SDS preoperatively (mean  -0.28; SD 0.26); 27.7% (n=48) and 13.3% (n=23) reduced >0.25 and >0.5 BMI SDS respectively. In several cases, obesity reduced sufficiently to reduce at least one weight category (22.0%, n=38), no longer be classified “severely obese” (12.7%, n=22), no longer have insulin resistance or liver dysfunction, require CPAP for OSA or post-operative HDU beds.

Lessons learnt

Over half of children were in the lowest two deciles of deprivation (Figure 1). Families value being listened to in a non-judgemental face-to-face setting with an individualised multidisciplinary approach. Outcomes from lifestyle intervention in this setting have superseded expectations; families facing imminent increased perioperative risks may be more motivated to adopt positive behavioural change.

Message for others

As health professionals, everyone has a role in health promotion and ensuring sustainability. This initiative has shown that by capitalising on this “teachable moment”, significant perioperative risk-modification and health benefits are feasible, with potential for longer term health and socioeconomic effects.

References:

1. Burton ZA, Lewis R, Bennett T, McLernon DJ; Paediatric Anaesthesia Trainee Research Network; Engelhardt T, Brooks PB, Edwards MR. Prevalence of PErioperAtive CHildhood obesitY in children undergoing general anaesthesia in the UK: a prospective, multicentre, observational cohort study. Br J Anaesth. 2021 Dec;127(6):953-961.
2. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016 Feb;17(2):95-107.
3. Burton ZA, Saddington F, Russell K and the Society for Obesity and Bariatric Anaesthesia, 2023. Anaesthesia consent for children and young people living with obesity. https://www.sobauk.co.uk/guidelines-1 (Accessed 1st February 2024)
4. Reinehr T, Lass N, Toschke C, Rothermel J, Lanzinger S, Holl RW. Which amount of BMI-SDS reduction is necessary to improve cardiovascular risk factors in overweight children? J Clin Endocrinol Metab (2016) 101.

O1

Perioperative Paracetamol Prescribing in Obese and Overweight Children: Secondary Analysis of the PErioperAtive ChildHood ObesitY (PEACHY) Study

F. L. Wensley¹, S. Heikal², H. Lewis³, T. Bennett⁴, M. R. Edwards¹, Z. A. Burton⁵, Paediatric Anaesthesia Trainee Research Network (PATRN)⁶

¹University Hospital London NHS Foundation Trust, NIHR Southampton Biomedical Research Centre, Southampton, UK

²Elisabeth Twee-Steden Zeikenhuis, Tilburg, The Netherlands

³Evelina Children's Hospital, London, UK

⁴University Hospital London NHS Foundation Trust, Southampton, UK

⁵Sheffield Children's NHS Foundation Trust, UK

⁶Paediatric Anaesthesia Trainee Research Network, London, UK

Introduction and aims

Paracetamol is the most frequently prescribed and administered analgesic agent for children undergoing surgery in the UK. Prescribing is traditionally based on total body weight or age-specific oral or rectal doses. However, there is limited evidence on how best to adjust the dose for children living with overweight and obesity, who make up almost a quarter of the UK paediatric surgical population.[1] Severely obese children often have underlying cardiometabolic and liver dysfunction, and fatty liver disease may increase susceptibility to paracetamol hepatotoxicity.[2] Furthermore, a lack of drug-specific pharmacokinetic data for this patient group, combined with limited expert guidance, has left individual prescribers to determine when dose adjustment is necessary and how to adjust it.  We aimed to quantify paracetamol dosing in overweight and obese patients, demonstrate variation between UK centres and to understand prescribing practices.

Methods

PEACHY Study methodology has been published previously.[1] All paediatric patients (2 to 15 years old) undergoing elective, day-case or emergency procedures under general anaesthesia were eligible for inclusion. Patient demographics, surgical procedure, height, weight, paracetamol doses prescribed, intraoperative care and complications, and immediate postoperative care were documented. Adjusted body weight was calculated according to recent clinical guidance.[3] Data were excluded for not meeting the age criteria, insufficient information to calculate BMI, immediate postoperative admission to PICU and non-painful procedures (e.g. MRI). Patients who were not prescribed paracetamol perioperatively, or were appropriately prescribed a maximal 1g dose, were also excluded from analysis. We analysed paracetamol prescriptions comparing total and adjusted body weight doses across 102 UK sites.

Results

3275 patients were included in the current analyses. Of these, 20.2% (662) were overweight or obese. There was significant variation in dose across BMI categories, with overweight, obese and severely obese patients receiving lower doses per kilogram of total body weight (mean [SD] 14.83 [2.45], 13.88 [2.45] and 12.76 [3.55] mg.kg-1 respectively) compared to normal or underweight patients (15.83 [2.84] and 15.49 [2.50] respectively, P-value for ANOVA < 0.001). Paracetamol dose varied significantly across sites (figure). Mean adjusted body weight doses for overweight, obese and severely obese patients were 16.91 (2.79), 16.81 (2.92) and 17.11 (4.64), respectively.

Discussion and conclusion

This is the first national, prospective, multi-centre study reporting on perioperative paracetamol prescribing in children in the UK. There is a wide range in dose prescribed for overweight and obese patients. However, there is evidence that anaesthetists are attempting to adjust for excess body weight in this population, using an estimate between adjusted and total body weight. This work supports recent guidelines,[3,4] which suggest that adjusted body weight dose might be a safe approach to avoid risk associated with overdose in this potentially vulnerable population.

References:

1. Burton Z, Lewis R, Bennett T et al. Prevalence of PErioperAtive CHildhood obesitY in children undergoing general anaesthesia in the UK: a prospective, multicentre, observational cohort study. British Journal of Anaesthesia. 2021; 127 (6): 953e961
2. Skinner AC, Perrin EM, Moss LA, Skelton JA. Cardiometabolic Risks and Severity of Obesity in Children and Young Adults. N Engl J Med. 2015 Oct;373(14):1307-17. doi: 10.1056/NEJMoa1502821. PMID: 26422721.
3. Burton Z, Russell K, Saddington F et al. Anesthesia for Children living with Obesity. Single Sheet Guideline. Available from: https://www.sobauk.co.uk/guidelines-1 (Last accessed 11th November 2023).
4. UKMi. NPPG. How should medicines be dosed in children who are obese? 2021. https://www.sps.nhs.uk/articles/how-should-medicines-be-dosed-in-children-who-are-obese/. Last accessed 03/12/2022.