Society of Hospital Medicine (SHM)/ Ambulatory Pediatric Association/ American Academy of Pediatrics (AAP): Pediatric Hospital Medicine 2011

Nebulized hypertonic saline is an emerging therapy for this indication.

Viral bronchiolitis is the most common diagnosis at hospitalization for infants younger than 1 year of age.

It results in approximately 150,000 hospitalizations each year at a cost of more than $500 million, according to a study published in 2006 (Pediatrics 2006;118:2418-23). Yet so far, nothing we give our patients really works.

Nebulized hypertonic saline is garnering enthusiasm because there is a consistent set of papers and a theory of physiology supporting its efficacy in the treatment of acute viral bronchiolitis.

The very first hypertonic saline study came from a group of Israeli pulmonologists who reported an improvement in symptoms and respiratory scores on day 2 of inhaled nebulized 3% saline solution plus 5-mg terbutaline in 33 outpatient infants with viral bronchiolitis, compared with 32 control infants who received 0.9% saline plus 5 mg terbutaline (Chest 2002;122:2015-20).

The findings led the researchers to conduct a second randomized, controlled study, this time combining 3% hypertonic saline with 1.5-mg epinephrine three times a day until discharge among 27 hospitalized infants. Clinical severity scores improved significantly after 24 hours of therapy and almost a full day was shaved off the length of stay (LOS), compared with normal saline plus epinephrine in 25 infants (Chest 2003;123:481-7).

The group came back a year later with a second year of follow-up in 41 inpatients and essentially replicated their findings (Isr. Med. Assoc. J. 2006;8:169-73).

The study that caught most hospitalists’ eyes, however, was a multicenter, double-blind Canadian trial that left the concomitant use of beta-agonists up to the discretion of the physicians who treated 96 infants hospitalized with moderately severe viral bronchiolitis (J. Pediatr. 2007;151:266-70). Even though 30% of the infants did not receive beta-agonists, the use of hypertonic saline resulted in a clinically relevant 26% reduction in LOS (from 3.5 days to 2.6 days) with normal saline. Symptoms diverged the longer the infants were treated.

Short-term improvement was not really expected, based on the theory that hypertonic saline works by rehydrating the airway surface liquid (ASL), as well as inducing cough and improving sputum mobility. The Israelis theorized that mucociliary failure, such as occurs in cystic fibrosis, also occurs in severe bronchiolitis because of dehydration of the ASL, the thin layer of fluid that covers the luminal surface of the airway.

In vitro, hypertonic saline increases airway surface thickness, decreases epithelial edema, and improves mucus rheology and transport rates. In vivo, it increases mucociliary transport in healthy subjects.

Thus, it makes sense that short-term studies have found no difference in outcomes, and that studies demonstrating positive effects on LOS and respiratory scores do so only after 24 hours of therapy. Fluid shifts take time, and cilia can only do so much.

Chinese investigators have reported similar positive outcomes, including a reduction in LOS from 7.4 to 6 days with hypertonic saline plus salbutamol in hospitalized infants (Pediatr. Int. 2010;52:199-202). Moreover, these findings were replicated in a second study, this time using nebulized 3% hypertonic saline without concomitant bronchodilators (Clin. Microbiol. Infect. 2010 July 15 [Epub ahead of print]).

We’ve never seen this level of consistently positive results in the data on bronchiolitis treatment in the past, and it’s exciting – particularly as we have so little in our therapeutic armamentarium. It’s also very interesting to have a theory of mechanism of action that meshes with the known pathology in bronchiolitis. After years of repeatedly studying beta-agonists, even though we knew that airway smooth muscle reactivity was not the major pathology, it is refreshing to see a different approach emerging.

Dr. Ralston is chief of inpatient pediatrics at the University of Texas Health Science Center in San Antonio. She said she had no relevant financial disclosures.

It is too early to say if hypertonic saline is an appropriate therapy.

Much of the evidence supporting the use of nebulized hypertonic saline for acute bronchiolitis rests on changes in respiratory scores that are not likely to have clinical relevance. The true test is whether hypertonic saline can really reduce length of stay (LOS), the hard outcome that hospitalists and parents care about. That question remains unanswered.

No fewer than five short-term emergency department (ED) studies have failed to find a difference in outcomes between nebulized hypertonic saline and normal saline. One of those trials was by the same group of Canadian researchers that helped put nebulized hypertonic saline on the radar of many hospitalists and pediatricians (J. Pediatr. 2007;151:266-70).

When the Canadians studied hypertonic saline in the ED setting, there were no significant differences in hospital admission rates or respiratory scores after three consecutive 4-mL doses of nebulized 3% hypertonic saline in children younger than age 2 years who presented to the ED with moderately severe bronchiolitis (CJEM 2010;12:477-84).

In addition, no large randomized trials from the United States have been conducted using our criteria for hospitalization. A recent Chinese study demonstrated a reduction in LOS with the use of hypertonic saline plus salbutamol in 93 infants hospitalized with mild to moderate bronchiolitis (Pediatr. Int. 2010;52:199-202). The reduction, however, was from 7.4 days to 6.0 days – an LOS that was more than double the U.S. average LOS of 2.5 days.

The same researchers evaluated nebulized 3% hypertonic saline without bronchodilators, and reported a similar reduction in LOS from an average of 6.4 days with normal saline to a full 4.8 days with hypertonic saline (Clin. Microbiol. Infect. 2010 July 15 [Epub ahead of print]).

Dr. Susan Wu and her colleagues at Childrens Hospital Los Angeles presented data, however, at the recent Pediatric Hospital Medicine 2011 meeting that contradicts these findings. Although the preliminary analysis includes subjects from only the first 2 years of the study and was not fully powered for the LOS outcome, hypertonic saline was no better than normal saline for respiratory distress, and actually resulted in a longer LOS of 3.46 days compared with 2.74 days with normal saline (Pediatric Hospital Medicine 2011;1 [poster session B, July 29] abstract 4).

One also has to question whether the cost of respiratory therapy labor to provide such a potentially ineffective therapy can be justified in the current health care environment, when hypertonic saline hasn’t been established as being superior to the guideline recommendation of supportive care only.

Some may argue that the cost of hypertonic saline is free, but a quick back-of-the-envelope calculation would suggest otherwise. If you practice in a 90-bed hospital, see 500 bronchiolitis patients per year, and have a 3-day LOS using hypertonic saline every 4 hours, that works out to 12,000 nebulizations and 400 hours of respiratory time, which ends up costing $300,000 per year. At that price tag, one could hire a full-time employee for your hospitalist team.

Many administrations may also insist that hypertonic saline be given with albuterol, which one could argue may in some cases actually extend LOS because of the potential for patients to desaturate.

Finally, if you’re a fee-for-service hospital, there’s a financial disincentive for your administration to spend $300,000 for a therapy that could actually reduce profits by shortening LOS. Hospitals adopt measures that shorten LOS, but few would be willing to implement such a strategy until a large, randomized, controlled trial conducted in the United States has proved that hypertonic saline, likely without albuterol, is both clinically and cost effective.

Dr. Alverson is director of pediatric hospital medicine at Hasbro Children’s Hospital in Providence, R.I. He said that he had no relevant financial disclosures.

This column, Point/Counterpoint, regularly appears in Pediatric News, an Elsevier publication.

Nebulized hypertonic saline is an emerging therapy for this indication.

Viral bronchiolitis is the most common diagnosis at hospitalization for infants younger than 1 year of age.

It results in approximately 150,000 hospitalizations each year at a cost of more than $500 million, according to a study published in 2006 (Pediatrics 2006;118:2418-23). Yet so far, nothing we give our patients really works.

Nebulized hypertonic saline is garnering enthusiasm because there is a consistent set of papers and a theory of physiology supporting its efficacy in the treatment of acute viral bronchiolitis.

The very first hypertonic saline study came from a group of Israeli pulmonologists who reported an improvement in symptoms and respiratory scores on day 2 of inhaled nebulized 3% saline solution plus 5-mg terbutaline in 33 outpatient infants with viral bronchiolitis, compared with 32 control infants who received 0.9% saline plus 5 mg terbutaline (Chest 2002;122:2015-20).

The findings led the researchers to conduct a second randomized, controlled study, this time combining 3% hypertonic saline with 1.5-mg epinephrine three times a day until discharge among 27 hospitalized infants. Clinical severity scores improved significantly after 24 hours of therapy and almost a full day was shaved off the length of stay (LOS), compared with normal saline plus epinephrine in 25 infants (Chest 2003;123:481-7).

The group came back a year later with a second year of follow-up in 41 inpatients and essentially replicated their findings (Isr. Med. Assoc. J. 2006;8:169-73).

The study that caught most hospitalists’ eyes, however, was a multicenter, double-blind Canadian trial that left the concomitant use of beta-agonists up to the discretion of the physicians who treated 96 infants hospitalized with moderately severe viral bronchiolitis (J. Pediatr. 2007;151:266-70). Even though 30% of the infants did not receive beta-agonists, the use of hypertonic saline resulted in a clinically relevant 26% reduction in LOS (from 3.5 days to 2.6 days) with normal saline. Symptoms diverged the longer the infants were treated.

Short-term improvement was not really expected, based on the theory that hypertonic saline works by rehydrating the airway surface liquid (ASL), as well as inducing cough and improving sputum mobility. The Israelis theorized that mucociliary failure, such as occurs in cystic fibrosis, also occurs in severe bronchiolitis because of dehydration of the ASL, the thin layer of fluid that covers the luminal surface of the airway.

In vitro, hypertonic saline increases airway surface thickness, decreases epithelial edema, and improves mucus rheology and transport rates. In vivo, it increases mucociliary transport in healthy subjects.

Thus, it makes sense that short-term studies have found no difference in outcomes, and that studies demonstrating positive effects on LOS and respiratory scores do so only after 24 hours of therapy. Fluid shifts take time, and cilia can only do so much.

Chinese investigators have reported similar positive outcomes, including a reduction in LOS from 7.4 to 6 days with hypertonic saline plus salbutamol in hospitalized infants (Pediatr. Int. 2010;52:199-202). Moreover, these findings were replicated in a second study, this time using nebulized 3% hypertonic saline without concomitant bronchodilators (Clin. Microbiol. Infect. 2010 July 15 [Epub ahead of print]).

We’ve never seen this level of consistently positive results in the data on bronchiolitis treatment in the past, and it’s exciting – particularly as we have so little in our therapeutic armamentarium. It’s also very interesting to have a theory of mechanism of action that meshes with the known pathology in bronchiolitis. After years of repeatedly studying beta-agonists, even though we knew that airway smooth muscle reactivity was not the major pathology, it is refreshing to see a different approach emerging.

Dr. Ralston is chief of inpatient pediatrics at the University of Texas Health Science Center in San Antonio. She said she had no relevant financial disclosures.

It is too early to say if hypertonic saline is an appropriate therapy.

Much of the evidence supporting the use of nebulized hypertonic saline for acute bronchiolitis rests on changes in respiratory scores that are not likely to have clinical relevance. The true test is whether hypertonic saline can really reduce length of stay (LOS), the hard outcome that hospitalists and parents care about. That question remains unanswered.

No fewer than five short-term emergency department (ED) studies have failed to find a difference in outcomes between nebulized hypertonic saline and normal saline. One of those trials was by the same group of Canadian researchers that helped put nebulized hypertonic saline on the radar of many hospitalists and pediatricians (J. Pediatr. 2007;151:266-70).

When the Canadians studied hypertonic saline in the ED setting, there were no significant differences in hospital admission rates or respiratory scores after three consecutive 4-mL doses of nebulized 3% hypertonic saline in children younger than age 2 years who presented to the ED with moderately severe bronchiolitis (CJEM 2010;12:477-84).

In addition, no large randomized trials from the United States have been conducted using our criteria for hospitalization. A recent Chinese study demonstrated a reduction in LOS with the use of hypertonic saline plus salbutamol in 93 infants hospitalized with mild to moderate bronchiolitis (Pediatr. Int. 2010;52:199-202). The reduction, however, was from 7.4 days to 6.0 days – an LOS that was more than double the U.S. average LOS of 2.5 days.

The same researchers evaluated nebulized 3% hypertonic saline without bronchodilators, and reported a similar reduction in LOS from an average of 6.4 days with normal saline to a full 4.8 days with hypertonic saline (Clin. Microbiol. Infect. 2010 July 15 [Epub ahead of print]).

Dr. Susan Wu and her colleagues at Childrens Hospital Los Angeles presented data, however, at the recent Pediatric Hospital Medicine 2011 meeting that contradicts these findings. Although the preliminary analysis includes subjects from only the first 2 years of the study and was not fully powered for the LOS outcome, hypertonic saline was no better than normal saline for respiratory distress, and actually resulted in a longer LOS of 3.46 days compared with 2.74 days with normal saline (Pediatric Hospital Medicine 2011;1 [poster session B, July 29] abstract 4).

One also has to question whether the cost of respiratory therapy labor to provide such a potentially ineffective therapy can be justified in the current health care environment, when hypertonic saline hasn’t been established as being superior to the guideline recommendation of supportive care only.

Some may argue that the cost of hypertonic saline is free, but a quick back-of-the-envelope calculation would suggest otherwise. If you practice in a 90-bed hospital, see 500 bronchiolitis patients per year, and have a 3-day LOS using hypertonic saline every 4 hours, that works out to 12,000 nebulizations and 400 hours of respiratory time, which ends up costing $300,000 per year. At that price tag, one could hire a full-time employee for your hospitalist team.

Many administrations may also insist that hypertonic saline be given with albuterol, which one could argue may in some cases actually extend LOS because of the potential for patients to desaturate.

Finally, if you’re a fee-for-service hospital, there’s a financial disincentive for your administration to spend $300,000 for a therapy that could actually reduce profits by shortening LOS. Hospitals adopt measures that shorten LOS, but few would be willing to implement such a strategy until a large, randomized, controlled trial conducted in the United States has proved that hypertonic saline, likely without albuterol, is both clinically and cost effective.

Dr. Alverson is director of pediatric hospital medicine at Hasbro Children’s Hospital in Providence, R.I. He said that he had no relevant financial disclosures.

This column, Point/Counterpoint, regularly appears in Pediatric News, an Elsevier publication.

Nebulized hypertonic saline is an emerging therapy for this indication.

Viral bronchiolitis is the most common diagnosis at hospitalization for infants younger than 1 year of age.

It results in approximately 150,000 hospitalizations each year at a cost of more than $500 million, according to a study published in 2006 (Pediatrics 2006;118:2418-23). Yet so far, nothing we give our patients really works.

Nebulized hypertonic saline is garnering enthusiasm because there is a consistent set of papers and a theory of physiology supporting its efficacy in the treatment of acute viral bronchiolitis.

The very first hypertonic saline study came from a group of Israeli pulmonologists who reported an improvement in symptoms and respiratory scores on day 2 of inhaled nebulized 3% saline solution plus 5-mg terbutaline in 33 outpatient infants with viral bronchiolitis, compared with 32 control infants who received 0.9% saline plus 5 mg terbutaline (Chest 2002;122:2015-20).

The findings led the researchers to conduct a second randomized, controlled study, this time combining 3% hypertonic saline with 1.5-mg epinephrine three times a day until discharge among 27 hospitalized infants. Clinical severity scores improved significantly after 24 hours of therapy and almost a full day was shaved off the length of stay (LOS), compared with normal saline plus epinephrine in 25 infants (Chest 2003;123:481-7).

The group came back a year later with a second year of follow-up in 41 inpatients and essentially replicated their findings (Isr. Med. Assoc. J. 2006;8:169-73).

The study that caught most hospitalists’ eyes, however, was a multicenter, double-blind Canadian trial that left the concomitant use of beta-agonists up to the discretion of the physicians who treated 96 infants hospitalized with moderately severe viral bronchiolitis (J. Pediatr. 2007;151:266-70). Even though 30% of the infants did not receive beta-agonists, the use of hypertonic saline resulted in a clinically relevant 26% reduction in LOS (from 3.5 days to 2.6 days) with normal saline. Symptoms diverged the longer the infants were treated.

Short-term improvement was not really expected, based on the theory that hypertonic saline works by rehydrating the airway surface liquid (ASL), as well as inducing cough and improving sputum mobility. The Israelis theorized that mucociliary failure, such as occurs in cystic fibrosis, also occurs in severe bronchiolitis because of dehydration of the ASL, the thin layer of fluid that covers the luminal surface of the airway.

In vitro, hypertonic saline increases airway surface thickness, decreases epithelial edema, and improves mucus rheology and transport rates. In vivo, it increases mucociliary transport in healthy subjects.

Thus, it makes sense that short-term studies have found no difference in outcomes, and that studies demonstrating positive effects on LOS and respiratory scores do so only after 24 hours of therapy. Fluid shifts take time, and cilia can only do so much.

Chinese investigators have reported similar positive outcomes, including a reduction in LOS from 7.4 to 6 days with hypertonic saline plus salbutamol in hospitalized infants (Pediatr. Int. 2010;52:199-202). Moreover, these findings were replicated in a second study, this time using nebulized 3% hypertonic saline without concomitant bronchodilators (Clin. Microbiol. Infect. 2010 July 15 [Epub ahead of print]).

We’ve never seen this level of consistently positive results in the data on bronchiolitis treatment in the past, and it’s exciting – particularly as we have so little in our therapeutic armamentarium. It’s also very interesting to have a theory of mechanism of action that meshes with the known pathology in bronchiolitis. After years of repeatedly studying beta-agonists, even though we knew that airway smooth muscle reactivity was not the major pathology, it is refreshing to see a different approach emerging.

Dr. Ralston is chief of inpatient pediatrics at the University of Texas Health Science Center in San Antonio. She said she had no relevant financial disclosures.

It is too early to say if hypertonic saline is an appropriate therapy.

Much of the evidence supporting the use of nebulized hypertonic saline for acute bronchiolitis rests on changes in respiratory scores that are not likely to have clinical relevance. The true test is whether hypertonic saline can really reduce length of stay (LOS), the hard outcome that hospitalists and parents care about. That question remains unanswered.

No fewer than five short-term emergency department (ED) studies have failed to find a difference in outcomes between nebulized hypertonic saline and normal saline. One of those trials was by the same group of Canadian researchers that helped put nebulized hypertonic saline on the radar of many hospitalists and pediatricians (J. Pediatr. 2007;151:266-70).

When the Canadians studied hypertonic saline in the ED setting, there were no significant differences in hospital admission rates or respiratory scores after three consecutive 4-mL doses of nebulized 3% hypertonic saline in children younger than age 2 years who presented to the ED with moderately severe bronchiolitis (CJEM 2010;12:477-84).

In addition, no large randomized trials from the United States have been conducted using our criteria for hospitalization. A recent Chinese study demonstrated a reduction in LOS with the use of hypertonic saline plus salbutamol in 93 infants hospitalized with mild to moderate bronchiolitis (Pediatr. Int. 2010;52:199-202). The reduction, however, was from 7.4 days to 6.0 days – an LOS that was more than double the U.S. average LOS of 2.5 days.

The same researchers evaluated nebulized 3% hypertonic saline without bronchodilators, and reported a similar reduction in LOS from an average of 6.4 days with normal saline to a full 4.8 days with hypertonic saline (Clin. Microbiol. Infect. 2010 July 15 [Epub ahead of print]).

Dr. Susan Wu and her colleagues at Childrens Hospital Los Angeles presented data, however, at the recent Pediatric Hospital Medicine 2011 meeting that contradicts these findings. Although the preliminary analysis includes subjects from only the first 2 years of the study and was not fully powered for the LOS outcome, hypertonic saline was no better than normal saline for respiratory distress, and actually resulted in a longer LOS of 3.46 days compared with 2.74 days with normal saline (Pediatric Hospital Medicine 2011;1 [poster session B, July 29] abstract 4).

One also has to question whether the cost of respiratory therapy labor to provide such a potentially ineffective therapy can be justified in the current health care environment, when hypertonic saline hasn’t been established as being superior to the guideline recommendation of supportive care only.

Some may argue that the cost of hypertonic saline is free, but a quick back-of-the-envelope calculation would suggest otherwise. If you practice in a 90-bed hospital, see 500 bronchiolitis patients per year, and have a 3-day LOS using hypertonic saline every 4 hours, that works out to 12,000 nebulizations and 400 hours of respiratory time, which ends up costing $300,000 per year. At that price tag, one could hire a full-time employee for your hospitalist team.

Many administrations may also insist that hypertonic saline be given with albuterol, which one could argue may in some cases actually extend LOS because of the potential for patients to desaturate.

Finally, if you’re a fee-for-service hospital, there’s a financial disincentive for your administration to spend $300,000 for a therapy that could actually reduce profits by shortening LOS. Hospitals adopt measures that shorten LOS, but few would be willing to implement such a strategy until a large, randomized, controlled trial conducted in the United States has proved that hypertonic saline, likely without albuterol, is both clinically and cost effective.

Dr. Alverson is director of pediatric hospital medicine at Hasbro Children’s Hospital in Providence, R.I. He said that he had no relevant financial disclosures.

This column, Point/Counterpoint, regularly appears in Pediatric News, an Elsevier publication.

KANSAS CITY, MO. – Seventeen percent of American children and adolescents are obese, and an increasing number of them are landing in operating rooms for related issues. They bring to the table particular perioperative concerns.

Dr. Moises Auron of the Cleveland Clinic offered an example during a talk on pediatric perioperative management at the Pediatric Hospital Medicine 2011 meeting: A 15-year-old African American with a body mass index of 60 kg/m², fasting blood glucose of 115 mg/dL, and glycated hemoglobin of 6.4%, and who smokes, requires pinning of his hip for slipped capital femoral epiphysis.

For this high-risk patient, he said, cardiovascular concerns top the list, because obese children and adolescents are predisposed to hypertension at roughly a threefold higher risk than nonobese children. As a result, they can develop left ventricular hypertrophy that can produce a hypertrophic cardiomyopathy–like scenario, as well as diastolic dysfunction that also can predispose them to develop heart failure.

Childhood obesity is typically defined as a BMI at or above the 95th percentile for age and sex, while morbid obesity, as in the above patient, is a BMI that exceeds the 99th percentile.

Three times as many U.S. youth are obese now as were just one generation ago, the most recent data from the Centers for Disease Control and Prevention suggest. In addition, one in seven low-income, preschool-aged children is obese.

"Unfortunately, we are seeing more and more and more of these cases," said Dr. Auron, a pediatric hospitalist with the Center for Pediatric Hospital Medicine at the Cleveland Clinic.

Obese patients may require surgery not only for a variety of common ailments such as tonsillitis, but also for obesity-related conditions such as slipped capital femoral epiphysis, Blount’s disease, cholelithiasis, and polycystic ovary syndrome. In addition, they present with comorbid conditions such as insulin resistance, hypertension, and idiopathic intracranial hypertension.

What to Look for in Obese Patients

In the examination of these patients, Dr. Auron suggests that the history include any symptoms of sleep apnea or hypoventilation, such as falling asleep while watching television or when talking with friends, and poor tolerance to exercise, including breathlessness and asthma, because these may in fact represent symptoms of left ventricular dysfunction.

Documentation of recent weight loss or gain, as well as a careful history of current medications – especially herbs or special mixtures taken to lose weight – is paramount. Weight loss may be associated with malnutrition, while the use of common herbs can interfere with anesthesia or hemostasis and even be associated with tachycardia, hypertension, or dysrhythmias.

"Garlic and ginger are very good antiplatelet agents," he said. "It’s like taking baby aspirin, but it’s not good if you’re having surgery. You can bleed to death.

"Medications that contain ephedra can trigger a severe sympathetic response, including hypertensive crises and tachyarrhythmias."

Other perioperative considerations to be wary of in the morbidly obese pediatric patient are diabetes/insulin resistance; gastroesophageal reflux; and nonalcoholic fatty liver disease (NAFLD), including its progressive form, nonalcoholic steatohepatitis (NASH).

"When they develop NASH, it can evolve to cirrhosis, horribly," Dr. Auron said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. "It’s even worse than alcoholic cirrhosis or viral hepatitis cirrhosis. I’m not sure why this is, but it causes substantial morbidity in the obese population who develops it."

The prevalence of NAFLD and NASH varies by setting. Among 41 morbidly obese adolescents aged 13-19 years undergoing gastric bypass surgery, 83% had NAFLD and 20% had NASH. Mean fasting glucose was significantly higher in those with NASH, although the prevalence of the metabolic syndrome was not (Gastroenterol. Hepatol. 2006;4:226-32).

A second study, however, recently reported that fatty liver disease, independent of visceral fat and intramyocellular lipid content, plays a central role in the pathogenesis of insulin resistance in obese adolescents (Diabetes Care 2010;33:1817-22).

Dr. Auron said he recommends echocardiography for hypertensive patients, although he noted that there is not a lot of evidence, even in the adult literature, to support an echocardiogram for every patient. The one exception is patients with cardiomegaly on x-ray; echocardiography is recommended for this patient group (Circulation 2009;120:86-95).

Preoperative fasting should follow the same rules as for nonobese patients, albeit perhaps a bit more fasting would not lead obese patients astray, he said, tongue in cheek.

Dr. Auron reported no relevant financial relationships.

KANSAS CITY, MO. – Seventeen percent of American children and adolescents are obese, and an increasing number of them are landing in operating rooms for related issues. They bring to the table particular perioperative concerns.

Dr. Moises Auron of the Cleveland Clinic offered an example during a talk on pediatric perioperative management at the Pediatric Hospital Medicine 2011 meeting: A 15-year-old African American with a body mass index of 60 kg/m², fasting blood glucose of 115 mg/dL, and glycated hemoglobin of 6.4%, and who smokes, requires pinning of his hip for slipped capital femoral epiphysis.

For this high-risk patient, he said, cardiovascular concerns top the list, because obese children and adolescents are predisposed to hypertension at roughly a threefold higher risk than nonobese children. As a result, they can develop left ventricular hypertrophy that can produce a hypertrophic cardiomyopathy–like scenario, as well as diastolic dysfunction that also can predispose them to develop heart failure.

Childhood obesity is typically defined as a BMI at or above the 95th percentile for age and sex, while morbid obesity, as in the above patient, is a BMI that exceeds the 99th percentile.

Three times as many U.S. youth are obese now as were just one generation ago, the most recent data from the Centers for Disease Control and Prevention suggest. In addition, one in seven low-income, preschool-aged children is obese.

"Unfortunately, we are seeing more and more and more of these cases," said Dr. Auron, a pediatric hospitalist with the Center for Pediatric Hospital Medicine at the Cleveland Clinic.

Obese patients may require surgery not only for a variety of common ailments such as tonsillitis, but also for obesity-related conditions such as slipped capital femoral epiphysis, Blount’s disease, cholelithiasis, and polycystic ovary syndrome. In addition, they present with comorbid conditions such as insulin resistance, hypertension, and idiopathic intracranial hypertension.

What to Look for in Obese Patients

In the examination of these patients, Dr. Auron suggests that the history include any symptoms of sleep apnea or hypoventilation, such as falling asleep while watching television or when talking with friends, and poor tolerance to exercise, including breathlessness and asthma, because these may in fact represent symptoms of left ventricular dysfunction.

Documentation of recent weight loss or gain, as well as a careful history of current medications – especially herbs or special mixtures taken to lose weight – is paramount. Weight loss may be associated with malnutrition, while the use of common herbs can interfere with anesthesia or hemostasis and even be associated with tachycardia, hypertension, or dysrhythmias.

"Garlic and ginger are very good antiplatelet agents," he said. "It’s like taking baby aspirin, but it’s not good if you’re having surgery. You can bleed to death.

"Medications that contain ephedra can trigger a severe sympathetic response, including hypertensive crises and tachyarrhythmias."

Other perioperative considerations to be wary of in the morbidly obese pediatric patient are diabetes/insulin resistance; gastroesophageal reflux; and nonalcoholic fatty liver disease (NAFLD), including its progressive form, nonalcoholic steatohepatitis (NASH).

"When they develop NASH, it can evolve to cirrhosis, horribly," Dr. Auron said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. "It’s even worse than alcoholic cirrhosis or viral hepatitis cirrhosis. I’m not sure why this is, but it causes substantial morbidity in the obese population who develops it."

The prevalence of NAFLD and NASH varies by setting. Among 41 morbidly obese adolescents aged 13-19 years undergoing gastric bypass surgery, 83% had NAFLD and 20% had NASH. Mean fasting glucose was significantly higher in those with NASH, although the prevalence of the metabolic syndrome was not (Gastroenterol. Hepatol. 2006;4:226-32).

A second study, however, recently reported that fatty liver disease, independent of visceral fat and intramyocellular lipid content, plays a central role in the pathogenesis of insulin resistance in obese adolescents (Diabetes Care 2010;33:1817-22).

Dr. Auron said he recommends echocardiography for hypertensive patients, although he noted that there is not a lot of evidence, even in the adult literature, to support an echocardiogram for every patient. The one exception is patients with cardiomegaly on x-ray; echocardiography is recommended for this patient group (Circulation 2009;120:86-95).

Preoperative fasting should follow the same rules as for nonobese patients, albeit perhaps a bit more fasting would not lead obese patients astray, he said, tongue in cheek.

Dr. Auron reported no relevant financial relationships.

KANSAS CITY, MO. – Seventeen percent of American children and adolescents are obese, and an increasing number of them are landing in operating rooms for related issues. They bring to the table particular perioperative concerns.

Dr. Moises Auron of the Cleveland Clinic offered an example during a talk on pediatric perioperative management at the Pediatric Hospital Medicine 2011 meeting: A 15-year-old African American with a body mass index of 60 kg/m², fasting blood glucose of 115 mg/dL, and glycated hemoglobin of 6.4%, and who smokes, requires pinning of his hip for slipped capital femoral epiphysis.

For this high-risk patient, he said, cardiovascular concerns top the list, because obese children and adolescents are predisposed to hypertension at roughly a threefold higher risk than nonobese children. As a result, they can develop left ventricular hypertrophy that can produce a hypertrophic cardiomyopathy–like scenario, as well as diastolic dysfunction that also can predispose them to develop heart failure.

Childhood obesity is typically defined as a BMI at or above the 95th percentile for age and sex, while morbid obesity, as in the above patient, is a BMI that exceeds the 99th percentile.

Three times as many U.S. youth are obese now as were just one generation ago, the most recent data from the Centers for Disease Control and Prevention suggest. In addition, one in seven low-income, preschool-aged children is obese.

"Unfortunately, we are seeing more and more and more of these cases," said Dr. Auron, a pediatric hospitalist with the Center for Pediatric Hospital Medicine at the Cleveland Clinic.

Obese patients may require surgery not only for a variety of common ailments such as tonsillitis, but also for obesity-related conditions such as slipped capital femoral epiphysis, Blount’s disease, cholelithiasis, and polycystic ovary syndrome. In addition, they present with comorbid conditions such as insulin resistance, hypertension, and idiopathic intracranial hypertension.

What to Look for in Obese Patients

In the examination of these patients, Dr. Auron suggests that the history include any symptoms of sleep apnea or hypoventilation, such as falling asleep while watching television or when talking with friends, and poor tolerance to exercise, including breathlessness and asthma, because these may in fact represent symptoms of left ventricular dysfunction.

Documentation of recent weight loss or gain, as well as a careful history of current medications – especially herbs or special mixtures taken to lose weight – is paramount. Weight loss may be associated with malnutrition, while the use of common herbs can interfere with anesthesia or hemostasis and even be associated with tachycardia, hypertension, or dysrhythmias.

"Garlic and ginger are very good antiplatelet agents," he said. "It’s like taking baby aspirin, but it’s not good if you’re having surgery. You can bleed to death.

"Medications that contain ephedra can trigger a severe sympathetic response, including hypertensive crises and tachyarrhythmias."

Other perioperative considerations to be wary of in the morbidly obese pediatric patient are diabetes/insulin resistance; gastroesophageal reflux; and nonalcoholic fatty liver disease (NAFLD), including its progressive form, nonalcoholic steatohepatitis (NASH).

"When they develop NASH, it can evolve to cirrhosis, horribly," Dr. Auron said at the meeting sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. "It’s even worse than alcoholic cirrhosis or viral hepatitis cirrhosis. I’m not sure why this is, but it causes substantial morbidity in the obese population who develops it."

The prevalence of NAFLD and NASH varies by setting. Among 41 morbidly obese adolescents aged 13-19 years undergoing gastric bypass surgery, 83% had NAFLD and 20% had NASH. Mean fasting glucose was significantly higher in those with NASH, although the prevalence of the metabolic syndrome was not (Gastroenterol. Hepatol. 2006;4:226-32).

A second study, however, recently reported that fatty liver disease, independent of visceral fat and intramyocellular lipid content, plays a central role in the pathogenesis of insulin resistance in obese adolescents (Diabetes Care 2010;33:1817-22).

Dr. Auron said he recommends echocardiography for hypertensive patients, although he noted that there is not a lot of evidence, even in the adult literature, to support an echocardiogram for every patient. The one exception is patients with cardiomegaly on x-ray; echocardiography is recommended for this patient group (Circulation 2009;120:86-95).

Preoperative fasting should follow the same rules as for nonobese patients, albeit perhaps a bit more fasting would not lead obese patients astray, he said, tongue in cheek.

Dr. Auron reported no relevant financial relationships.

KANSAS CITY, MO. – The use of a resident handoff bundle was associated with significant reductions in overall medical errors, regardless of whether a computerized tool linking the electronic medical record was present or not.

Rates of errors, including those that harmed patients, near misses, and minor errors, significantly decreased from 32% to 19% in a unit with the full intervention and from 45% to 25% in a unit with all but the computerized tool. The rate of decline between the two units was not significantly different.

The two general inpatient units at Children’s Hospital Boston had relatively similar patient populations and size, the same resident call system, and the identical preexisting system for verbal and written handoffs, lead author Dr. Amy J. Starmer explained during the plenary session at the Pediatric Hospital Medicine 2011 meeting.

A review of randomly selected sign-out documents also found that several key elements were present significantly more often after implementation of the resident handoff bundle (RHB).

The research intervention featured three components, including communication and handoff skills training for resident physicians, adapted in large part from TeamSTEPPS, a communication and teamwork skills program developed by the Department of Defense and the Agency for Healthcare Research and Quality.

Secondly, the investigators attempted to standardize verbal handoffs by putting a verbal mnemonic in place, restructuring the process so that all residents and interns were brought together as a team and enforcing the process with intermittent evaluations and feedback from the chief resident.

Finally, a computerized handoff tool was introduced in Unit 1 that allowed for pre-text entry of key information fields and automatic importing of information such as demographics, medications, or patient code status, said Dr. Starmer, a pediatrician at Children’s Hospital. Unit 2 used a Microsoft Word document for these written tasks.

Outcomes were measured 3 months pre- and post-intervention using previously standardized error surveillance methods, a review of 107 electronic copies of daily printed sign-outs, and a written miscommunication abstraction tool with 14 key data elements. In all, 529 patient entries were reviewed for Unit 1 and 204 for Unit 2.

Based on the review of Unit 1, certain items were uniformly included preintervention such as name (97%), medical record number (97%), chief complaint (97%), allergies (95%), weight (94%), and patient summary (75%), while others such as medication list (3%), code status (2%), lab results (1%), and vital signs with date (0%) were rarely present, Dr. Starmer said.

All of the aforementioned items, except for chief complaint (99%) and patient summary (95%), were present in 100% of reports postintervention, likely because the data were being automatically imported, she said. Improvements also were observed for more complex items such as to-do lists (29% pre vs. 82% post) and contingency plans (18% vs. 47%), likely because of computer prompting. All comparisons, except chief complaint, were statistically significant (P less than .05).

In Unit 2, significant gains were observed in the inclusion of contingency plans (25% pre vs. 40% post), lab results with date (7% vs. 17%), and vital signs with date (2% vs. 9%) (P less than .05 for all), Dr. Starmer said.

Upward trends were noted for the routinely included items of chief complaint (96% vs. 100%), weight (99% vs. 100%), and patient summary (96% vs. 100%), with slight declines in allergies (94% vs. 91%) and code status (3% vs. 2%). Name and medical record number were included in 100% of records pre- and postintervention.

Limitations of the study include the inability to control for resident learning over time and seasonal variations, its single-site design, and the inability to sustain the use of the verbal mnemonic following the research period, said Dr. Starmer at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

She went on to say that these limitations will be addressed in I-PASS (IIPE-PRIS Accelerating Safe Sign-Outs), a multicenter study supported by the Initiative for Innovation in Pediatric Education (IIPE) and the Pediatric Research in Inpatient Settings (PRIS) network.

An attendee asked how the team approach to resident-intern verbal signoffs has been impacted by new resident work hours. Dr. Starmer said there was some concern that the new work rules would affect the amount of time spent with each patient, but that this has not changed.

Dr. Starmer and her coauthors reported no relevant financial relationships.

KANSAS CITY, MO. – The use of a resident handoff bundle was associated with significant reductions in overall medical errors, regardless of whether a computerized tool linking the electronic medical record was present or not.

Rates of errors, including those that harmed patients, near misses, and minor errors, significantly decreased from 32% to 19% in a unit with the full intervention and from 45% to 25% in a unit with all but the computerized tool. The rate of decline between the two units was not significantly different.

The two general inpatient units at Children’s Hospital Boston had relatively similar patient populations and size, the same resident call system, and the identical preexisting system for verbal and written handoffs, lead author Dr. Amy J. Starmer explained during the plenary session at the Pediatric Hospital Medicine 2011 meeting.

A review of randomly selected sign-out documents also found that several key elements were present significantly more often after implementation of the resident handoff bundle (RHB).

The research intervention featured three components, including communication and handoff skills training for resident physicians, adapted in large part from TeamSTEPPS, a communication and teamwork skills program developed by the Department of Defense and the Agency for Healthcare Research and Quality.

Secondly, the investigators attempted to standardize verbal handoffs by putting a verbal mnemonic in place, restructuring the process so that all residents and interns were brought together as a team and enforcing the process with intermittent evaluations and feedback from the chief resident.

Finally, a computerized handoff tool was introduced in Unit 1 that allowed for pre-text entry of key information fields and automatic importing of information such as demographics, medications, or patient code status, said Dr. Starmer, a pediatrician at Children’s Hospital. Unit 2 used a Microsoft Word document for these written tasks.

Outcomes were measured 3 months pre- and post-intervention using previously standardized error surveillance methods, a review of 107 electronic copies of daily printed sign-outs, and a written miscommunication abstraction tool with 14 key data elements. In all, 529 patient entries were reviewed for Unit 1 and 204 for Unit 2.

Based on the review of Unit 1, certain items were uniformly included preintervention such as name (97%), medical record number (97%), chief complaint (97%), allergies (95%), weight (94%), and patient summary (75%), while others such as medication list (3%), code status (2%), lab results (1%), and vital signs with date (0%) were rarely present, Dr. Starmer said.

All of the aforementioned items, except for chief complaint (99%) and patient summary (95%), were present in 100% of reports postintervention, likely because the data were being automatically imported, she said. Improvements also were observed for more complex items such as to-do lists (29% pre vs. 82% post) and contingency plans (18% vs. 47%), likely because of computer prompting. All comparisons, except chief complaint, were statistically significant (P less than .05).

In Unit 2, significant gains were observed in the inclusion of contingency plans (25% pre vs. 40% post), lab results with date (7% vs. 17%), and vital signs with date (2% vs. 9%) (P less than .05 for all), Dr. Starmer said.

Upward trends were noted for the routinely included items of chief complaint (96% vs. 100%), weight (99% vs. 100%), and patient summary (96% vs. 100%), with slight declines in allergies (94% vs. 91%) and code status (3% vs. 2%). Name and medical record number were included in 100% of records pre- and postintervention.

Limitations of the study include the inability to control for resident learning over time and seasonal variations, its single-site design, and the inability to sustain the use of the verbal mnemonic following the research period, said Dr. Starmer at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

She went on to say that these limitations will be addressed in I-PASS (IIPE-PRIS Accelerating Safe Sign-Outs), a multicenter study supported by the Initiative for Innovation in Pediatric Education (IIPE) and the Pediatric Research in Inpatient Settings (PRIS) network.

An attendee asked how the team approach to resident-intern verbal signoffs has been impacted by new resident work hours. Dr. Starmer said there was some concern that the new work rules would affect the amount of time spent with each patient, but that this has not changed.

Dr. Starmer and her coauthors reported no relevant financial relationships.

KANSAS CITY, MO. – The use of a resident handoff bundle was associated with significant reductions in overall medical errors, regardless of whether a computerized tool linking the electronic medical record was present or not.

Rates of errors, including those that harmed patients, near misses, and minor errors, significantly decreased from 32% to 19% in a unit with the full intervention and from 45% to 25% in a unit with all but the computerized tool. The rate of decline between the two units was not significantly different.

The two general inpatient units at Children’s Hospital Boston had relatively similar patient populations and size, the same resident call system, and the identical preexisting system for verbal and written handoffs, lead author Dr. Amy J. Starmer explained during the plenary session at the Pediatric Hospital Medicine 2011 meeting.

A review of randomly selected sign-out documents also found that several key elements were present significantly more often after implementation of the resident handoff bundle (RHB).

The research intervention featured three components, including communication and handoff skills training for resident physicians, adapted in large part from TeamSTEPPS, a communication and teamwork skills program developed by the Department of Defense and the Agency for Healthcare Research and Quality.

Secondly, the investigators attempted to standardize verbal handoffs by putting a verbal mnemonic in place, restructuring the process so that all residents and interns were brought together as a team and enforcing the process with intermittent evaluations and feedback from the chief resident.

Finally, a computerized handoff tool was introduced in Unit 1 that allowed for pre-text entry of key information fields and automatic importing of information such as demographics, medications, or patient code status, said Dr. Starmer, a pediatrician at Children’s Hospital. Unit 2 used a Microsoft Word document for these written tasks.

Outcomes were measured 3 months pre- and post-intervention using previously standardized error surveillance methods, a review of 107 electronic copies of daily printed sign-outs, and a written miscommunication abstraction tool with 14 key data elements. In all, 529 patient entries were reviewed for Unit 1 and 204 for Unit 2.

Based on the review of Unit 1, certain items were uniformly included preintervention such as name (97%), medical record number (97%), chief complaint (97%), allergies (95%), weight (94%), and patient summary (75%), while others such as medication list (3%), code status (2%), lab results (1%), and vital signs with date (0%) were rarely present, Dr. Starmer said.

All of the aforementioned items, except for chief complaint (99%) and patient summary (95%), were present in 100% of reports postintervention, likely because the data were being automatically imported, she said. Improvements also were observed for more complex items such as to-do lists (29% pre vs. 82% post) and contingency plans (18% vs. 47%), likely because of computer prompting. All comparisons, except chief complaint, were statistically significant (P less than .05).

In Unit 2, significant gains were observed in the inclusion of contingency plans (25% pre vs. 40% post), lab results with date (7% vs. 17%), and vital signs with date (2% vs. 9%) (P less than .05 for all), Dr. Starmer said.

Upward trends were noted for the routinely included items of chief complaint (96% vs. 100%), weight (99% vs. 100%), and patient summary (96% vs. 100%), with slight declines in allergies (94% vs. 91%) and code status (3% vs. 2%). Name and medical record number were included in 100% of records pre- and postintervention.

Limitations of the study include the inability to control for resident learning over time and seasonal variations, its single-site design, and the inability to sustain the use of the verbal mnemonic following the research period, said Dr. Starmer at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.

She went on to say that these limitations will be addressed in I-PASS (IIPE-PRIS Accelerating Safe Sign-Outs), a multicenter study supported by the Initiative for Innovation in Pediatric Education (IIPE) and the Pediatric Research in Inpatient Settings (PRIS) network.

An attendee asked how the team approach to resident-intern verbal signoffs has been impacted by new resident work hours. Dr. Starmer said there was some concern that the new work rules would affect the amount of time spent with each patient, but that this has not changed.

Dr. Starmer and her coauthors reported no relevant financial relationships.

KANSAS CITY, MO. – Improved patient selection and reduced use of oral midazolam are being credited with a fivefold decrease in adverse events associated with pediatric propofol sedation.

The rate of respiratory events, airway interventions, and any other event dropped from 11% in 2005 to 2.3% in 2009 among patients sedated with propofol (Diprivan) by hospitalists in an ambulatory procedure center at St. Louis Children’s Hospital, according to an analysis of 1,649 patients.

Multivariate analysis showed that age more than 12 years (odds ratio 4.0), American Society of Anesthesiologists (ASA) 3 status (OR 2.3), premedication with oral midazolam (Versed) (OR 1.9), use of glycopyrrolate (Robinul) during sedation (OR 4.7), and history of snoring (OR 2.4) increased the likelihood of respiratory events.

All of these, except for ASA 3 status, also significantly increased the likelihood for airway interventions, Dr. Mythili Srinivasan and her colleagues reported in a poster at Pediatric Hospital Medicine 2011.

Although snoring and midazolam were the two most prevalent risk factors, the use of adjuvant glycopyrrolate was found to be the single greatest risk factor for both respiratory events (OR 4.7) and airway interventions (OR 5.8).

"However, a history of recent or ongoing upper respiratory infection was not a significant risk factor, raising the question of whether glycopyrrolate itself may be a risk factor for propofol sedation similar to that reported for ketamine sedations," said Dr. Srinivasan, a pediatric hospitalist at Washington University in St. Louis, Missouri.

A previous analysis of risk factors for ketamine sedation also showed that use of glycopyrrolate was associated with significantly more airway and respiratory complications in the emergency department than either atropine or no anticholinergic in an individual patient-data meta-analysis of 8,282 children (Ann. Emerg. Med. 2009;54:158-68).

In the current analysis, propofol dose, procedure time, and the diagnostic category of the patients were not significant risk factors for adverse events.

The higher likelihood of respiratory events and airway interventions in patients 12 years or older was described by the authors as an unexpected finding. The increase was not related to higher doses of propofol normalized to body weight, nor did older patients have a higher incidence of risk factors such as history of snoring, ASA 3 status, premedication with midazolam, or use of glycopyrrolate compared with patients younger than 12 years. Further studies are needed to explain the surprise finding, the authors suggested.

Declines during the study period in three of the five risk factors – age more than 12 years, ASA 3 status, and premedication with oral midazolam – were significantly correlated with the overall decrease in rates of adverse events, Dr. Srinivasan reported at the meeting, which was sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The percentage of patients older than 12 years dropped twofold from 8% in 2005 to 3.8% in 2009, while patients in the ASA 3 category decreased from 10% to 2%, and the use of oral midazolam fell from 41% to 3.3%.

Finally, the increased expertise of hospitalists in the use of propofol also likely contributed to the decrease in adverse events, she noted.

Dr. Srinivasan and her coauthors reported no relevant financial disclosures.

KANSAS CITY, MO. – Improved patient selection and reduced use of oral midazolam are being credited with a fivefold decrease in adverse events associated with pediatric propofol sedation.

The rate of respiratory events, airway interventions, and any other event dropped from 11% in 2005 to 2.3% in 2009 among patients sedated with propofol (Diprivan) by hospitalists in an ambulatory procedure center at St. Louis Children’s Hospital, according to an analysis of 1,649 patients.

Multivariate analysis showed that age more than 12 years (odds ratio 4.0), American Society of Anesthesiologists (ASA) 3 status (OR 2.3), premedication with oral midazolam (Versed) (OR 1.9), use of glycopyrrolate (Robinul) during sedation (OR 4.7), and history of snoring (OR 2.4) increased the likelihood of respiratory events.

All of these, except for ASA 3 status, also significantly increased the likelihood for airway interventions, Dr. Mythili Srinivasan and her colleagues reported in a poster at Pediatric Hospital Medicine 2011.

Although snoring and midazolam were the two most prevalent risk factors, the use of adjuvant glycopyrrolate was found to be the single greatest risk factor for both respiratory events (OR 4.7) and airway interventions (OR 5.8).

"However, a history of recent or ongoing upper respiratory infection was not a significant risk factor, raising the question of whether glycopyrrolate itself may be a risk factor for propofol sedation similar to that reported for ketamine sedations," said Dr. Srinivasan, a pediatric hospitalist at Washington University in St. Louis, Missouri.

A previous analysis of risk factors for ketamine sedation also showed that use of glycopyrrolate was associated with significantly more airway and respiratory complications in the emergency department than either atropine or no anticholinergic in an individual patient-data meta-analysis of 8,282 children (Ann. Emerg. Med. 2009;54:158-68).

In the current analysis, propofol dose, procedure time, and the diagnostic category of the patients were not significant risk factors for adverse events.

The higher likelihood of respiratory events and airway interventions in patients 12 years or older was described by the authors as an unexpected finding. The increase was not related to higher doses of propofol normalized to body weight, nor did older patients have a higher incidence of risk factors such as history of snoring, ASA 3 status, premedication with midazolam, or use of glycopyrrolate compared with patients younger than 12 years. Further studies are needed to explain the surprise finding, the authors suggested.

Declines during the study period in three of the five risk factors – age more than 12 years, ASA 3 status, and premedication with oral midazolam – were significantly correlated with the overall decrease in rates of adverse events, Dr. Srinivasan reported at the meeting, which was sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The percentage of patients older than 12 years dropped twofold from 8% in 2005 to 3.8% in 2009, while patients in the ASA 3 category decreased from 10% to 2%, and the use of oral midazolam fell from 41% to 3.3%.

Finally, the increased expertise of hospitalists in the use of propofol also likely contributed to the decrease in adverse events, she noted.

Dr. Srinivasan and her coauthors reported no relevant financial disclosures.

KANSAS CITY, MO. – Improved patient selection and reduced use of oral midazolam are being credited with a fivefold decrease in adverse events associated with pediatric propofol sedation.

The rate of respiratory events, airway interventions, and any other event dropped from 11% in 2005 to 2.3% in 2009 among patients sedated with propofol (Diprivan) by hospitalists in an ambulatory procedure center at St. Louis Children’s Hospital, according to an analysis of 1,649 patients.

Multivariate analysis showed that age more than 12 years (odds ratio 4.0), American Society of Anesthesiologists (ASA) 3 status (OR 2.3), premedication with oral midazolam (Versed) (OR 1.9), use of glycopyrrolate (Robinul) during sedation (OR 4.7), and history of snoring (OR 2.4) increased the likelihood of respiratory events.

All of these, except for ASA 3 status, also significantly increased the likelihood for airway interventions, Dr. Mythili Srinivasan and her colleagues reported in a poster at Pediatric Hospital Medicine 2011.

Although snoring and midazolam were the two most prevalent risk factors, the use of adjuvant glycopyrrolate was found to be the single greatest risk factor for both respiratory events (OR 4.7) and airway interventions (OR 5.8).

"However, a history of recent or ongoing upper respiratory infection was not a significant risk factor, raising the question of whether glycopyrrolate itself may be a risk factor for propofol sedation similar to that reported for ketamine sedations," said Dr. Srinivasan, a pediatric hospitalist at Washington University in St. Louis, Missouri.

A previous analysis of risk factors for ketamine sedation also showed that use of glycopyrrolate was associated with significantly more airway and respiratory complications in the emergency department than either atropine or no anticholinergic in an individual patient-data meta-analysis of 8,282 children (Ann. Emerg. Med. 2009;54:158-68).

In the current analysis, propofol dose, procedure time, and the diagnostic category of the patients were not significant risk factors for adverse events.

The higher likelihood of respiratory events and airway interventions in patients 12 years or older was described by the authors as an unexpected finding. The increase was not related to higher doses of propofol normalized to body weight, nor did older patients have a higher incidence of risk factors such as history of snoring, ASA 3 status, premedication with midazolam, or use of glycopyrrolate compared with patients younger than 12 years. Further studies are needed to explain the surprise finding, the authors suggested.

Declines during the study period in three of the five risk factors – age more than 12 years, ASA 3 status, and premedication with oral midazolam – were significantly correlated with the overall decrease in rates of adverse events, Dr. Srinivasan reported at the meeting, which was sponsored by the Society of Hospital Medicine, American Academy of Pediatrics, and Academic Pediatric Association.

The percentage of patients older than 12 years dropped twofold from 8% in 2005 to 3.8% in 2009, while patients in the ASA 3 category decreased from 10% to 2%, and the use of oral midazolam fell from 41% to 3.3%.

Finally, the increased expertise of hospitalists in the use of propofol also likely contributed to the decrease in adverse events, she noted.

Dr. Srinivasan and her coauthors reported no relevant financial disclosures.

KANSAS CITY, MO. – The use of a socioeconomic-based risk index early in the hospital encounter can identify children at significantly increased risk of asthma readmission and family financial strain, a secondary analysis suggests.

The study of 601 patients with asthma found that children classified at high social risk had more than double the risk of hospital readmission or return emergency department visit within 12 months than did those at low risk, according to Dr. Andrew Beck, a pediatrics fellow at Cincinnati Children’s Hospital Medical Center, and his colleagues.

In addition, patients at high risk had nearly 15-fold increased odds of reporting two or more financial hardships.

Patrice Wendling/Elsevier Global Medical News

Dr. Beck observed that area-based geographic data is used routinely in public health for surveillance, resource allocation, and deprivation assessment but not at the bedside, where electronic medical records can improve data linkages from the moment patients register with their address.

"We don’t routinely use this data to identify patients who may be at increased social risk," he said during the plenary session at Pediatric Hospital Medicine 2011. "Every child receives the same basic, acute-oriented medical care, potentially missing the opportunity to inform other hospital, social, and medical interventions."

To illustrate his point, Dr. Beck pointed to a 20-fold difference in asthma admissions among patients aged 1-17 years and a 10-fold difference in median household income between Cincinnati’s tony, east-side Hyde Park neighborhood and the historic, urban Over-the-Rhine neighborhood. Some Cincinnati neighborhoods have no residents living in poverty, while others have 50% of children living below the poverty line.

The researchers devised a point-of-first-contact (PFC) risk index using the patient’s insurance status and U.S. census tract variables of poverty rate, home value, and education that were geographically coded to the patient’s address and zip code. One point was given if patients were on the "at-risk" side of the national median for each variable and another given if they were publicly insured or uninsured. Race/ethnicity was not included because of the potential for misclassification.

Analyzing the Backgrounds of Asthmatic Children

Based on the index, 117 of the 601 children, aged 1-16 years, in the prospective cohort, were at low risk (0 points), 201 were at medium risk (1-2 points), and 283 at high risk (3-4 points), he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and Academic Pediatric Association.

A total of 237 children (39%) returned to the ED or were readmitted within 12 months. Overall, 73% of the low-risk group had not returned to the hospital, compared with 64% of the medium-risk and 53% of the high-risk group, he said.

When this association was assessed in a Cox model using the low-risk group as the reference, the risk of reutilization was increased 70% among those at medium risk (hazard ratio, 1.7) and more than double among those at high risk (HR, 2.3).

The researchers then measured family financial strain in face-to-face interviews with caregivers using five validated questions chosen for their likelihood of leading to intervention. In all, 38% of families reported not having enough money to make ends meet, 11% said they did not have enough food to eat, 23% were unable to pay the full rent/mortgage, 39% were unable to pay full utilities, and 13% were forced to move in with others for financial reasons.

Nearly one-third (32%) of the sample answered "yes" to two or more financial strain questions. The odds of reporting two or more financial hardships were 14.8-fold higher for the high-risk group and 7.9-fold higher for the medium-risk group, which was statistically significant (both P value less than .0001), Dr. Beck said. Interestingly, this correlation had a high sensitivity (97%) and negative predictive value (95%), illustrating the index’s value as a screening tool, he added.

"Because the PFC index is based on data available so early on in the admission encounter and triage, we believe it could be used to quickly triage who may and who may not benefit from further assessment and intervention by deriving a risk profile before you even enter the room," Dr. Beck concluded.

The Value in Determining Patient Risk

Session co-moderator Dr. Karen Wilson of the University of Rochester (N.Y.) agreed that the data could be readily available but said more work needs to be done to determine how patients would react if told by an ED physician they were at risk based on where they live.

"It is a novel idea that I think deserves further investigation, but it’s probably not something, just based on our IT system, that is practical to use right now because we don’t have the computer systems to automatically generate that census tract information," she said in an interview.

Fellow comoderator Dr. Mike Dean, chief of pediatric critical care at the University of Utah in Salt Lake City, asked whether it would suffice to simply determine whether patients lived in an area of extreme poverty according to census data rather than using a more complex and completely automated index. Dr. Beck said that approach would be feasible and that a significant effect size was observed even when the variable of extreme poverty was evaluated in isolation

Overall, 57% of children in the analysis lived in a census tract where more than 3.3% of the population lived below the 50% poverty line, 65% lived in a tract with a median home value of $106,700 or less, and 36% lived in a tract where 18% or more of adults lacked a high school education.

A total of 64% of the cohort was male, 53% were black, their mean age was 5.9 years, and 65% had public insurance or no insurance.

Dr. Beck, his coauthors, and Dr. Dean report no relevant financial relationships. Dr. Wilson reports a research grant from Child Health Corp. of America.

KANSAS CITY, MO. – The use of a socioeconomic-based risk index early in the hospital encounter can identify children at significantly increased risk of asthma readmission and family financial strain, a secondary analysis suggests.

The study of 601 patients with asthma found that children classified at high social risk had more than double the risk of hospital readmission or return emergency department visit within 12 months than did those at low risk, according to Dr. Andrew Beck, a pediatrics fellow at Cincinnati Children’s Hospital Medical Center, and his colleagues.

In addition, patients at high risk had nearly 15-fold increased odds of reporting two or more financial hardships.

Patrice Wendling/Elsevier Global Medical News

Dr. Beck observed that area-based geographic data is used routinely in public health for surveillance, resource allocation, and deprivation assessment but not at the bedside, where electronic medical records can improve data linkages from the moment patients register with their address.

"We don’t routinely use this data to identify patients who may be at increased social risk," he said during the plenary session at Pediatric Hospital Medicine 2011. "Every child receives the same basic, acute-oriented medical care, potentially missing the opportunity to inform other hospital, social, and medical interventions."

To illustrate his point, Dr. Beck pointed to a 20-fold difference in asthma admissions among patients aged 1-17 years and a 10-fold difference in median household income between Cincinnati’s tony, east-side Hyde Park neighborhood and the historic, urban Over-the-Rhine neighborhood. Some Cincinnati neighborhoods have no residents living in poverty, while others have 50% of children living below the poverty line.

The researchers devised a point-of-first-contact (PFC) risk index using the patient’s insurance status and U.S. census tract variables of poverty rate, home value, and education that were geographically coded to the patient’s address and zip code. One point was given if patients were on the "at-risk" side of the national median for each variable and another given if they were publicly insured or uninsured. Race/ethnicity was not included because of the potential for misclassification.

Analyzing the Backgrounds of Asthmatic Children

Based on the index, 117 of the 601 children, aged 1-16 years, in the prospective cohort, were at low risk (0 points), 201 were at medium risk (1-2 points), and 283 at high risk (3-4 points), he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and Academic Pediatric Association.

A total of 237 children (39%) returned to the ED or were readmitted within 12 months. Overall, 73% of the low-risk group had not returned to the hospital, compared with 64% of the medium-risk and 53% of the high-risk group, he said.

When this association was assessed in a Cox model using the low-risk group as the reference, the risk of reutilization was increased 70% among those at medium risk (hazard ratio, 1.7) and more than double among those at high risk (HR, 2.3).

The researchers then measured family financial strain in face-to-face interviews with caregivers using five validated questions chosen for their likelihood of leading to intervention. In all, 38% of families reported not having enough money to make ends meet, 11% said they did not have enough food to eat, 23% were unable to pay the full rent/mortgage, 39% were unable to pay full utilities, and 13% were forced to move in with others for financial reasons.

Nearly one-third (32%) of the sample answered "yes" to two or more financial strain questions. The odds of reporting two or more financial hardships were 14.8-fold higher for the high-risk group and 7.9-fold higher for the medium-risk group, which was statistically significant (both P value less than .0001), Dr. Beck said. Interestingly, this correlation had a high sensitivity (97%) and negative predictive value (95%), illustrating the index’s value as a screening tool, he added.

"Because the PFC index is based on data available so early on in the admission encounter and triage, we believe it could be used to quickly triage who may and who may not benefit from further assessment and intervention by deriving a risk profile before you even enter the room," Dr. Beck concluded.

The Value in Determining Patient Risk

Session co-moderator Dr. Karen Wilson of the University of Rochester (N.Y.) agreed that the data could be readily available but said more work needs to be done to determine how patients would react if told by an ED physician they were at risk based on where they live.

"It is a novel idea that I think deserves further investigation, but it’s probably not something, just based on our IT system, that is practical to use right now because we don’t have the computer systems to automatically generate that census tract information," she said in an interview.

Fellow comoderator Dr. Mike Dean, chief of pediatric critical care at the University of Utah in Salt Lake City, asked whether it would suffice to simply determine whether patients lived in an area of extreme poverty according to census data rather than using a more complex and completely automated index. Dr. Beck said that approach would be feasible and that a significant effect size was observed even when the variable of extreme poverty was evaluated in isolation

Overall, 57% of children in the analysis lived in a census tract where more than 3.3% of the population lived below the 50% poverty line, 65% lived in a tract with a median home value of $106,700 or less, and 36% lived in a tract where 18% or more of adults lacked a high school education.

A total of 64% of the cohort was male, 53% were black, their mean age was 5.9 years, and 65% had public insurance or no insurance.

Dr. Beck, his coauthors, and Dr. Dean report no relevant financial relationships. Dr. Wilson reports a research grant from Child Health Corp. of America.

KANSAS CITY, MO. – The use of a socioeconomic-based risk index early in the hospital encounter can identify children at significantly increased risk of asthma readmission and family financial strain, a secondary analysis suggests.

The study of 601 patients with asthma found that children classified at high social risk had more than double the risk of hospital readmission or return emergency department visit within 12 months than did those at low risk, according to Dr. Andrew Beck, a pediatrics fellow at Cincinnati Children’s Hospital Medical Center, and his colleagues.

In addition, patients at high risk had nearly 15-fold increased odds of reporting two or more financial hardships.

Patrice Wendling/Elsevier Global Medical News

Dr. Beck observed that area-based geographic data is used routinely in public health for surveillance, resource allocation, and deprivation assessment but not at the bedside, where electronic medical records can improve data linkages from the moment patients register with their address.

"We don’t routinely use this data to identify patients who may be at increased social risk," he said during the plenary session at Pediatric Hospital Medicine 2011. "Every child receives the same basic, acute-oriented medical care, potentially missing the opportunity to inform other hospital, social, and medical interventions."

To illustrate his point, Dr. Beck pointed to a 20-fold difference in asthma admissions among patients aged 1-17 years and a 10-fold difference in median household income between Cincinnati’s tony, east-side Hyde Park neighborhood and the historic, urban Over-the-Rhine neighborhood. Some Cincinnati neighborhoods have no residents living in poverty, while others have 50% of children living below the poverty line.

The researchers devised a point-of-first-contact (PFC) risk index using the patient’s insurance status and U.S. census tract variables of poverty rate, home value, and education that were geographically coded to the patient’s address and zip code. One point was given if patients were on the "at-risk" side of the national median for each variable and another given if they were publicly insured or uninsured. Race/ethnicity was not included because of the potential for misclassification.

Analyzing the Backgrounds of Asthmatic Children

Based on the index, 117 of the 601 children, aged 1-16 years, in the prospective cohort, were at low risk (0 points), 201 were at medium risk (1-2 points), and 283 at high risk (3-4 points), he said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and Academic Pediatric Association.

A total of 237 children (39%) returned to the ED or were readmitted within 12 months. Overall, 73% of the low-risk group had not returned to the hospital, compared with 64% of the medium-risk and 53% of the high-risk group, he said.

When this association was assessed in a Cox model using the low-risk group as the reference, the risk of reutilization was increased 70% among those at medium risk (hazard ratio, 1.7) and more than double among those at high risk (HR, 2.3).

The researchers then measured family financial strain in face-to-face interviews with caregivers using five validated questions chosen for their likelihood of leading to intervention. In all, 38% of families reported not having enough money to make ends meet, 11% said they did not have enough food to eat, 23% were unable to pay the full rent/mortgage, 39% were unable to pay full utilities, and 13% were forced to move in with others for financial reasons.

Nearly one-third (32%) of the sample answered "yes" to two or more financial strain questions. The odds of reporting two or more financial hardships were 14.8-fold higher for the high-risk group and 7.9-fold higher for the medium-risk group, which was statistically significant (both P value less than .0001), Dr. Beck said. Interestingly, this correlation had a high sensitivity (97%) and negative predictive value (95%), illustrating the index’s value as a screening tool, he added.

"Because the PFC index is based on data available so early on in the admission encounter and triage, we believe it could be used to quickly triage who may and who may not benefit from further assessment and intervention by deriving a risk profile before you even enter the room," Dr. Beck concluded.

The Value in Determining Patient Risk

Session co-moderator Dr. Karen Wilson of the University of Rochester (N.Y.) agreed that the data could be readily available but said more work needs to be done to determine how patients would react if told by an ED physician they were at risk based on where they live.

"It is a novel idea that I think deserves further investigation, but it’s probably not something, just based on our IT system, that is practical to use right now because we don’t have the computer systems to automatically generate that census tract information," she said in an interview.

Fellow comoderator Dr. Mike Dean, chief of pediatric critical care at the University of Utah in Salt Lake City, asked whether it would suffice to simply determine whether patients lived in an area of extreme poverty according to census data rather than using a more complex and completely automated index. Dr. Beck said that approach would be feasible and that a significant effect size was observed even when the variable of extreme poverty was evaluated in isolation

Overall, 57% of children in the analysis lived in a census tract where more than 3.3% of the population lived below the 50% poverty line, 65% lived in a tract with a median home value of $106,700 or less, and 36% lived in a tract where 18% or more of adults lacked a high school education.

A total of 64% of the cohort was male, 53% were black, their mean age was 5.9 years, and 65% had public insurance or no insurance.

Dr. Beck, his coauthors, and Dr. Dean report no relevant financial relationships. Dr. Wilson reports a research grant from Child Health Corp. of America.

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.

KANSAS CITY, MO. – Just four children experienced radiographic or spirometric abnormalities 6 months after hospitalization for complicated pneumonia in a prospective observational study involving 82 patients.

"Long-term sequelae from this condition are uncommon, and this may be important information for clinicians, patients, and parents in weighing various treatment decisions," study coauthor Dr. Sanjay Mahant said at the Pediatric Hospital Medicine 2011 meeting.

While the best management strategy for complicated pneumonia continues to be debated, there’s been increasing use of procedures, particularly chest tube placement with fibrinolytics such as tissue plasminogen activator and video-assisted thoracoscopic surgery.

The lack of long-term sequelae in the Canadian-based study is particularly remarkable in that 40 children received a chest drain with fibrinolytics and 11 received a chest drain alone, while the remaining were treated only with antibiotics.

"I still think larger studies are needed, but it’s really important when we’re discussing with families up front to explain why we’re doing these interventions," Dr. Mahant said. "We need to add in the mix that long-term outcomes are good regardless of whether we do antibiotics alone or an intervention, and what we’re really focusing on is reducing the short-term morbidity."

Research has focused almost entirely on short-term outcomes, with very few large, prospective studies available on how children with complicated pneumonia do over the long haul.

The current study is novel and important in that it looked not just at long-term lung function in a large prospective cohort, but also quality of life and outcomes relevant to families, session comoderator and pediatric infectious disease specialist Dr. Samir Shah said in an interview. He observed that a large portion of the children experienced short-term clinical phenomena in the study, but that these abnormalities appeared to resolve when followed out to 1 year.

"I think that’s very encouraging and good information to know, and will help inform our short-term treatment decisions, realizing that these kids seem to do well, somewhat or perhaps, no matter what we do," he said. "That may be helpful in prioritizing how invasive we need to be with drainage procedures and surgical procedures."

The study enrolled 82 children between October 2008 and October 2010 who were hospitalized with ultrasound evidence of pleural effusions with loculations. Their median age was 3.6 years and 55% were male.

Their median length of stay was 10 days, eight were admitted to the pediatric ICU, and none died, Dr. Mahant reported on behalf of principal investigator Dr. Eyal Cohen and their colleagues at the Hospital for Sick Children, University of Toronto. Six patients were readmitted within 1 month, of which three required treatment with a chest drain.

At 1 month follow-up, fever was reported in 15 (18%) children and persistent cough in 19 (23%). Failure to thrive was observed in two (2%). Among the 74 children evaluated at 6 months, 12 (16%) had persistent cough and none were feverish or failed to thrive.

A predicted forced expiratory volume in 1 second of 80% or less was reported in 7 (35%) of 20 patients at 1 month and only 1 (3.5%) of 28 patients evaluated at 6 months, he said at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. Spirometry results at 1 year in this patient were normal.

Persistent chest radiographic abnormalities, defined as effusion, pneumatocele or abscess, were noted in 24 (29%) of 82 patients at 1 month and 3 (4.6%) of 65 patients at 6 months. Chest x-rays were normal in two of the three children at 1 year, with one child lost to follow-up. A 7-year-old initially treated with a drain and no fibrinolytics required readmission, but he was among those with normal x-rays at 1 year, Dr. Mahant said.

The median time lost from school in the first month was 5 days, with 23% of parents reporting work loss. At 6 months, the median school loss was 2 days and just 9% of parents reported work loss.

Parent- and child-reported total scores on the Pediatric Quality of Life questionnaire were similar at 6 months to healthy controls. In addition, scores were significantly higher in the empyema cohort than in historical asthma controls (P value less than .001), he said.

While the data are encouraging, it is uncertain whether they will be enough to ratchet back the use of more invasive procedures, particularly in the United States. In addition, clinicians worldwide are facing an increasing incidence of complicated pneumonia since the 1990s due in part to pneumococcal serotype shift and antibacterial resistance, Dr. Mahant said.

Dr. Shah of Cincinnati Children’s Hospital Medical Center said the findings will give clinicians pause about whether invasive procedures are needed and the relative timing of these procedures. Moreover, researchers will recognize the importance of measuring long-term outcomes in future trials.

"I think that it’s critical to look at these [outcomes] because ultimately that is what matters," he said. "I think most people would be willing to trade a day or two in the hospital if whatever you’re doing led to fewer long-term symptoms."

Dr. Mahant and his coauthors reported a University of Toronto grant and funding from the SickKids Foundation. Dr. Shah reported no relevant financial disclosures.