P20 Evaluation of analgesic doses prescribed postoperatively for overweight and obese children

Abstract

has been using a smart-pump SCI library, interfaced with electronic infusion orders (Philips ICCA ®). The incidence of infusion errors is unknown. This study aims to determine the frequency, severity and distribution of smart-pump infusion errors and to identify contributory factors to the occurrence of infusion errors. Methods Programmed infusions are directly observed at the bedside. Parameters are compared against medication orders and auto-populated infusion data. Identified deviations are cat-egorised as either medication errors or discrepancies. Five opportunities for error (OEs) were identified: programming, administration, documentation, assignment, data transfer. Error rates (%) are calculated as: infusions with errors; and errors per OE. Pre-defined definitions, multidisciplinary consensus and grading processes are employed. Results A total of 1023 infusions for 175 patients were directly observed on 27 days between February and September 2017. 74% of patients were under 1 year, 32% under 1 month. The drug-library accommodated 96.5% of all infusions. Compliance with the drug-library was 98.9%. 55 infusions had ! 1 error (5.4%); a further 67 (6.3%) had ! 1 discrepancy. From a total of 4997 OEs, 72 errors (1.4%) and 107 discrepancies (2.1%) were observed. Documentation errors were most common; programming errors were rare (0.32% OE). Errors are minor, with just one requiring minimal intervention to prevent harm. Conclusion This study has highlighted the benefits of smart-pumps and auto-populated infusion data in the PICU setting. Identified error rates are low compared to similar studies. 4 The findings will contribute to the limited existing knowledge base on impact of these interventions on paediatric infusion administration errors. REFERENCES 1. Institute for Safe Medication Practices, ISMP. 2018-2019 Targeted medication safety best practices for hospitals 2018 [Available from: http://www.ismp.org/ tools/bestpractices/TMSBP-for-Hospitalsv2.pdf [Accessed: June 2019] 2. Oskarsdottir T, Harris D, Sutherland A, et al. A national scoping survey of standard infusions in paediatric and neonatal intensive care units in the United Kingdom. Aim In England, 17% of children aged 2-15 are considered obese and a further 13% overweight. 1 Physiological changes associated with obesity affect pharmacokinetic and pharmaco-dynamic parameters which may necessitate paediatric drug dose alteration although few guidelines exist to support this in clinical practice. This study aimed to:. determine the proportion of patients at a large paediatric hospital prescribed analgesics postoperatively who are obese or overweight. evaluate how analgesics are currently prescribed for these overweight and obese patients. determine whether doses are altered according to published recommendations. determine whether clinical outcomes differ for overweight or obese children compared to non-overweight children Method Postoperative paediatric inpatients aged 2-15 prescribed paracetamol, ibuprofen or morphine (or combination thereof) were included in the six-week prospective study. Demographic (age, weight, height, gender), prescription (drug name, dose, route, frequency) and clinical (surgical specialty, pain scores, paediatric early warning scores) information was collected from medical notes and drug charts. Patients with significant organ impairment or requiring intensive care were excluded. Body-mass-index centile (BMI-C) was calculated for each child using a validated web-based calculator and used to classify patients as non-overweight (BMI-C <91), overweight (BMI-C !91 and <98) or obese (BMI-C !98). Prescribed paracetamol and morphine doses were evaluated against patients' total body weight (TBW) and ideal body weight (IBW) and ibuprofen doses were evaluated against patients' TBW and lean body mass (LBM) 2 according to published dosing adjustment recommendations 2 3 and compared against formulary dosing standards. 4 Clinical outcome data was used to evaluate pain control and clinical status. Results BMI-C was calculated for 198 postoperative paediatric inpatients, and of these 142 (72%) were non-overweight , 27 (13.5%) were overweight and 29 (14.5%) were obese. Complete prescription and clinical data were available for 44 non-overweight, 22 overweight and 23 obese patients who were subjected to further analysis. Formulary dosing standards were 15 mg/kg for paracetamol, 5 mg/kg for ibuprofen and 0.1-0.2 mg/kg for morphine.[4] Mean postoperative oral paracetamol doses were 15.0 mg/TBW, 18.1 mg/IBW and 20.6 mg/IBW for non-overweight (n=43), overweight (n=22) and obese (n=23) patients respectively. Mean postoperative oral ibuprofen doses were 5.0 mg/TBW, 5.7 mg/LBM and 6.2 mg/LBM for non-overweight (n=37), overweight (n=16) and obese (n=21) patients respectively. Mean postoperative oral morphine doses were 0.14 mg/TBW, 0.17 mg/IBW and 0.18 mg/IBW for non-overweight (n=33), overweight (n=13) and obese (n=16) patients respectively. There was no significant difference in pain scores or paediatric early warning scores at 0-, 4-12-and 24-hours post-surgery between the three cohorts. Conclusion The proportion of patients in this study who were overweight or obese aligned with national prevalence data.[1] Children who were overweight or obese received higher doses of paracetamol, ibuprofen and morphine compared to non-overweight children, and doses of paracetamol and ibuprofen were greater than formulary dosing standards. This suggests that doses for obese or overweight children are not adequately adjusted according to IBW or LBM which may result in drug toxicity. Guidance for prescribers is need to aid identification of patients who are overweight or obese and to guide appropriate dose adjustment.