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This Week's Headlines:

More Overweight/Obese Children are Scheduled for Outpatient Surgery -- Are You Prepared?

The percentage of pediatric patients who are overweight or obese is increasing, along with the prevalence of conditions that often accompany extra weight, such as diabetes, hypertension, and sleep apnea. Children who are overweight and obese have a greater likelihood of experiencing problems associated with surgery, according to a recent study conducted by the University of Michigan Health System.¹

These patients may be among your most challenging; they frequently have complications and need longer monitoring, says Ann K. White, MD, FACS, FAAP, pediatric otolaryngologist at Atlanta Children's ENT in Alpharetta, GA.

In this day of frequent lawsuits, it's critical that you care for these patients in an appropriate facility so there isn't a delayed discharge or poor outcome. There are steps you can take to help this process. One is that the preoperative history and screening for these patients should be performed before the day of surgery so that the best surgical setting can be determined.

Some sources, including White, say the patient should be evaluated at least seven days before the date of surgery by the anesthesia providers so that more tests, if needed, can be done before the day of the procedure. Sleep apnea may be undiagnosed and may cause problems in terms of the preoperative sedation. The patient may need a sleep study, White says. Get any hypertension and diabetes under control before the surgery. Once the risks have been evaluated, the child may not be a candidate for an outpatient facility. Also know that you may run into challenges on the day of surgery, including appropriate drug dosing, says Paul Samuels, MD, associate professor of anesthesiology and pediatrics at Cincinnati Children's Hospital.

After surgery, the biggest challenge initially is making sure the patient is breathing adequately after extubation, White says. It's very important to monitor these patients appropriately; some require continuous positive airway pressure, Samuels says. Overweight/obese children also are more likely to need hospital admission for monitoring their oxygenation and ventilation, as well as bleeding, says Richard A. Beers, MD, professor of anesthesiology at State University of New York (SUNY) Upstate Medical University in Syracuse, NY. And don't forget that their preoperative co-morbities still have to be managed after surgery, Samuels says. Pain meds can complicate some diseases, he says. (For more on managing overweight and obese children in outpatient surgery, see the May issue of Same-Day Surgery. To subscribe, contact customerservice@ahcmedia.com or call (800) 688-2421).

Reference

1. Nafiu OO, Ndao-Brumblay KS, Bamgbade OA, et al. J National Med Assn 2007; 99:46-50.

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Parents Happy With Web-Based Informed Consent System

How would you like to use a new informed consent system that leads 90% of your patients and their parents to say that the system gave them a better understanding of how to take care of themselves before and after their procedure?

This new web-based informed consent system can help ensure parents of pediatric patients receive all necessary information. (A similar system is available for adult patients.) Nemours, a health care system based in Jacksonville, FL, developed the program through a collaborative agreement with Emmi Solutions, a multimedia communications company based in Chicago.

The EmmiKids program uses animated Web-based, interactive modules to help with parental informed consent for pediatric surgical, as well as medical, procedures. Module topics include general anesthesia, tonsillectomy and adenoidectomy, bilateral myringotomy, interventional cardiac catheterizations, inguinal hernia repair, repair of undescended testicles, hypospadius repair, and upper endoscopy. The system is intended to supplement a one-on-one conversation, not replace it. Parents can go back and review information as needed.

"The feedback from parents/guardians has been extremely favorable," says Barbara Price, administrative coordinator in the Department of Surgery, AI duPont Hospital for Children in Wilmington, DE. DuPont uses the modules for bilateral myringtomy and tonsillectomy. "Unanimously, parents report that they have an enhanced understanding of the surgical procedure itself as well as what to expect pre and post surgery," Price says.

The EmmiKids program provides information about the surgery that parents might not have understood from their meeting with the physician, says Jody Burks, ear, nose, and throat clinical coordinator at Nemours Childrens Clinic at DuPont.

"Parents often will forget to ask questions because the consult may be overwhelming for them," Burks says. "This gives them another opportunity to listen to the preoperative, surgery, and postoperative instructions." [A sample of the pediatric program is at www.emmisafety.com/pediatrics, and a sample of the adult program is available online at www.emmisafety.com. More information about pricing and other specifics of the system is available at www.emmisolutions.com. See additional information about EmmiKids in the upcoming issue of Same-Day Surgery.]

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Duke Health System Sued Again Over Hydraulic Fluid Mixup

A former patient has revived a lawsuit accusing the Duke University Health System (DUHS) in Durham, NC, of negligence related to an incident in which surgical instruments were mistakenly washed in used hydraulic fluid from the hospital elevators instead of sterilizing fluid.

DUHS confirmed in November 2004 that staff accidentally washed surgical tools in used elevator hydraulic fluid for two months, which resulted in the use of tainted instruments to treat approximately 3,800 patients. Bennie Holland underwent back surgery at Duke Health Raleigh Hospital Nov. 10, 2004, and he claims that the improperly cleaned instruments caused him a severe infection and chronic pain, according to information supplied by his attorney Brent Adams, JD, in Dunn, NC. Holland's lawsuit is the only one against Duke to come to light publicly so far.

DUHS recently released a statement explaining that it does not comment on pending litigation. In a statement issued in July 2006, when Holland's lawsuit was first filed, the hospital issued a statement saying, "We regret this incident occurred, but stand by the results of independent studies and our own analyses...[which] confirmed that the surgical instruments were fully sterile."

Holland withdrew his lawsuit without prejudice in August 2006, a maneuver that allowed him to re-file the case at a later date. In addition to suing DUHS, Holland was also the first of eight patients to file lawsuits against Automatic Elevator Co. of Durham and Cardinal Health, a medical supplies company based in Dublin, OH. For almost two months, the hospitals cleaned instruments with a solution of hot water and hydraulic fluid and then sterilized the instruments, according to sources. The problem was identified after hospital staff and surgeons noticed the surgical instruments were slick and oily, they say.

When the incident was first revealed in 2004, DUHS explained that employees of Automatic Elevator Co. of Durham mistakenly had filled empty detergent containers with the used hydraulic fluid in September 2004. The workers capped the soap containers without changing the labels. Cardinal Health redistributed the fluid to Duke Health Raleigh Hospital and Durham Regional Hospital in the same month.

After the incident became public, Duke officials created a web site for patients concerned about possible effects from surgery with the tainted instruments: http://hydraulicfluidfacts.dukehealth.org/.

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