Childhood obesity: a challenge for the anaesthetist?

Considerations for Intravenous Anesthesia Dose in Obese Children: Understanding PKPD

The intravenous induction or loading dose in children is commonly prescribed per kilogram. That dose recognizes the linear relationship between volume of distribution and total body weight. Total body weight comprises both fat and fat-free mass. Fat mass influences the volume of distribution and the use of total body weight fails to recognize the impact of fat mass on pharmacokinetics in children. Size metrics alternative to total body mass (e.g., fat-free and normal fat mass, ideal body weight and lean body weight) have been proposed to scale pharmacokinetic parameters (clearance, volume of distribution) for size. Clearance is the key parameter used to calculate infusion rates or maintenance dosing at steady state. Dosing schedules recognize the curvilinear relationship, described using allometric theory, between clearance and size. Fat mass also has an indirect influence on clearance through both metabolic and renal function that is independent of its effects due to increased body mass. Fat-free mass, lean body mass and ideal body mass are not drug specific and fail to recognize the variable impact of fat mass contributing to body composition in children, both lean and obese. Normal fat mass, used in conjunction with allometry, may prove a useful size metric but computation by clinicians for the individual child is not facile. Dosing is further complicated by the need for multicompartment models to describe intravenous drug pharmacokinetics and the concentration effect relationship, both beneficial and adverse, is often poorly understood. Obesity is also associated with other morbidity that may also influence pharmacokinetics. Dose is best determined using pharmacokinetic-pharmacodynamic (PKPD) models that account for these varied factors. These models, along with covariates (age, weight, body composition), can be incorporated into programmable target-controlled infusion pumps. The use of target-controlled infusion pumps, assuming practitioners have a sound understanding of the PKPD within programs, provide the best available guide to intravenous dose in obese children.

Prevalence of PErioperAtive CHildhood obesitY in children undergoing general anaesthesia in the UK: a prospective, multicentre, observational cohort study

BACKGROUND

Childhood obesity has become a serious global healthcare challenge. No UK data currently define its anaesthetic and perioperative implications. We aimed to determine obesity prevalence amongst UK children undergoing general anaesthesia and the incidence of predefined adverse perioperative events, and to compare perioperative obesity rates with National Child Measurement Programme (NCMP) data.

METHODS

During a site-selected consecutive 7-day study period, all children (2-16 yr) undergoing general anaesthesia were included. Anonymised hospital, surgical, and procedural details; demographic data; and adverse perioperative events were collected prospectively by Paediatric Anaesthesia Trainee Research Network (PATRN) collaborators.

RESULTS

For this study, 102 UK hospitals participated and 4232 cases were included in the final analysis; 76% of hospitals did not routinely calculate BMI. In addition, 3030 (71.6%; 95% confidence interval [CI]: 70.2-73.0%) children of healthy weight were compared with 537 (12.7%; 11.7-13.7%) children who were overweight and 478 (11.3%; 10.3-12.2%) children with obesity. Children with obesity (n=71; 14.9%) more commonly underwent (adeno)tonsillectomy than children of healthy weight (n=282; 9.3%; P<0.001; odds ratio [OR] 2.15; 95% CI: 1.58-2.92). Fewer children with obesity (n=365; 77% vs n=2552; 85%) were anaesthetised by consultant anaesthetists (OR 0.62; 95% CI: 0.48-0.79). Mask ventilation was difficult for 3.7% of children with obesity vs 0.6% of children of healthy weight (difference 3.0%; 95% CI: 1.3-4.7%; P<0.001). Comparison with NCMP data demonstrated an over-representation of obesity amongst the paediatric surgical population.

CONCLUSIONS

This large multicentre cohort study suggests a concerning prevalence of children with obesity presenting for anaesthesia. These results should be used to inform optimal provision of care for this population and support perioperative healthcare initiatives to address the burden of childhood obesity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03994419.

Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R ² = 0.71, B _max 876 mL/min, K ₅₀ 16.3 kg) and alfentanil (R ² = 0.70, B _{max (fixed)} 420 mL/min, K ₅₀ 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R ² = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R ² = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.

Clinical Considerations Regarding the Use of Obesity Pharmacotherapy in Adolescents with Obesity

A growing number of youth suffer from obesity and in particular severe obesity for which intensive lifestyle intervention does not adequately reduce excess adiposity. A treatment gap exists wherein effective treatment options for an adolescent with severe obesity include intensive lifestyle modification or metabolic and bariatric surgery while the application of obesity pharmacotherapy remains largely underutilized. These youth often present with numerous obesity-related comorbid diseases, including hypertension, dyslipidemia, prediabetes/type 2 diabetes, obstructive sleep apnea, nonalcoholic fatty liver disease, musculoskeletal problems, and psychosocial issues such as depression, anxiety, and social stigmatization. Current pediatric obesity treatment algorithms for pediatric primary care providers focus primarily on intensive lifestyle intervention with escalation of treatment intensity through four stages of intervention. Although a recent surge in the number of Food and Drug Administration-approved medications for obesity treatment has emerged in adults, pharmacotherapy options for youth remain limited. Recognizing treatment and knowledge gaps related to pharmacological agents and the urgent need for more effective treatment strategies in this population, discussed here are the efficacy, safety, and clinical application of obesity pharmacotherapy in youth with obesity based on current literature. Legal ramifications, informed consent regulations, and appropriate off-label use of these medications in pediatrics are included, focusing on prescribing practices and prescriber limits.

Advances in pharmacokinetic modeling: target controlled infusions in the obese

PURPOSE OF REVIEW

The use of conventional pharmacokinetic parameters sets 'models' derived from nonobese patients has proven inadequate to administer intravenous anesthetics in the obese population and is commonly associated with higher than anticipated plasma propofol concentrations when used with target (plasma or effect site) controlled infusion pumps. In this review we will describe recent modeling strategies to characterize the disposition of intravenous anesthetics in the obese patient and will show clinically relevant aspects of new model's performance in the obese population.

RECENT FINDINGS

Because clearance of a drug increases in a nonlinear manner with weight, nonlinear relationships better scale infusion rates between lean and obese individuals. Allometric concepts have been successfully used to describe size-related nonlinear changes in clearances. Other nonlinear scaling options include the use of descriptors such as body surface area, lean body weight, fat-free mass, and normal fat mass. Newer pharmacokinetic models, determined from obese patient data, have been developed for propofol and remifentanil using allometric concepts and comprehensive size descriptors.

SUMMARY

Pharmacokinetic models to perform target-controlled infusion in the obese population should incorporate descriptors that reflect with greater precision the influence of body composition in volumes and clearances of each drug. It is our hope that commercially available pumps will soon incorporate these new models to improve the performance of this technique in the obese population.

Obesity and Pediatric Drug Development

There is a lack of dosing guidelines for use in obese children. Moreover, the impact of obesity on drug safety and clinical outcomes is poorly defined. The paucity of information needed for the safe and effective use of drugs in obese patients remains a problem, even after drug approval. To assess the current incorporation of obesity as a covariate in pediatric drug development, the pediatric medical and clinical pharmacology reviews under the Food and Drug Administration (FDA) Amendments Act of 2007 and the FDA Safety and Innovation Act (FDASIA) of 2012 were reviewed for obesity studies. FDA labels were also reviewed for statements addressing obesity in pediatric patients. Forty-five drugs studied in pediatric patients under the FDA Amendments Act were found to have statements and key words in the medical and clinical pharmacology reviews and labels related to obesity. Forty-four products were identified similarly with pediatric studies under FDASIA. Of the 89 product labels identified, none provided dosing information related to obesity. The effect of body mass index on drug pharmacokinetics was mentioned in only 4 labels. We conclude that there is little information presently available to provide guidance related to dosing in obese pediatric patients. Moving forward, regulators, clinicians, and the pharmaceutical industry should consider situations in drug development in which the inclusion of obese patients in pediatric trials is necessary to facilitate the safe and effective use of new drug products in the obese pediatric population.

What is the best size predictor for dose in the obese child?

Lean body mass is commonly proposed for anesthesia maintenance drug dosing calculations. However, total body mass used with allometric scaling has been shown to be better for propofol in obese adults and children. Fat-free mass has also been used instead of lean body mass. Fat-free mass is essentially the same as lean body mass but excludes a small percentage of mass of lipids in cell membranes, CNS, and bone marrow. Normal fat mass is a size descriptor that partitions total body mass into fat-free mass and fat mass calculated from total body mass minus fat-free mass. The relative influence of fat mass compared with fat-free mass is described by the fraction of fat mass that makes fat equivalent to fat-free mass in terms of allometric size. This fraction (Ffat) will differ for each drug and each parameter affected by body size (eg, clearance and volume of distribution). This fraction is based on the concept of theory-based allometric size. The normal fat mass based on allometric theory and partition of body mass into fat and fat-free components provides a principle-based approach explaining size and body composition effects on pharmacokinetics of all drugs in children and in adults.

Correction to: Pharmacokinetics of Fentanyl and Its Derivatives in Children: A Comprehensive Review

Fentanyl and its derivatives sufentanil, alfentanil, and remifentanil are potent opioids. A comprehensive review of the use of fentanyl and its derivatives in the pediatric population was performed using the National Library of Medicine PubMed. Studies were included if they contained original pharmacokinetic parameters or models using established routes of administration in patients younger than 18 years of age. Of 372 retrieved articles, 44 eligible pharmacokinetic studies contained data of 821 patients younger than 18 years of age, including more than 46 preterm infants, 64 full-term neonates, 115 infants/toddlers, 188 children, and 28 adolescents. Underlying diagnoses included congenital heart and pulmonary disease and abdominal disorders. Routes of drug administration were intravenous, epidural, oral-transmucosal, intranasal, and transdermal. Despite extensive use in daily clinical practice, few studies have been performed. Preterm and term infants have lower clearance and protein binding. Pharmacokinetics was not altered by chronic renal or hepatic disease. Analyses of the pooled individual patients' data revealed that clearance maturation relating to body weight could be best described by the Hill function for sufentanil (R ² = 0.71, B _max 876 mL/min, K ₅₀ 16.3 kg) and alfentanil (R ² = 0.70, B _{max (fixed)} 420 mL/min, K ₅₀ 28 kg). The allometric exponent for estimation of clearance of sufentanil was 0.99 and 0.75 for alfentanil clearance. Maturation of remifentanil clearance was described by linear regression to bodyweight (R ² = 0.69). The allometric exponent for estimation of remifentanil clearance was 0.76. For fentanyl, linear regression showed only a weak correlation between clearance and bodyweight in preterm and term neonates (R ² = 0.22) owing to a lack of data in older age groups. A large heterogeneity regarding study design, clinical setting, drug administration, laboratory assays, and pharmacokinetic estimation was observed between studies introducing bias into the analyses performed in this review. A limitation of this review is that pharmacokinetic data, based on different modes of administration, dosing schemes, and parameter estimation methods, were combined.

Pilot study comparing post-anesthesia care unit length of stay in moderately and severely obese children

OBJECTIVE

Obesity is a risk factor for surgical complications in adults and children. Differences in postsurgical outcomes according to severity of obesity [moderate: 95-98th age-gender-specific body mass index (BMI) percentile versus severe: ≥99th percentile] in children remain unclear. This study compared post-anesthesia care unit (PACU) stay and hospital admission between severely obese children and moderately obese children undergoing surgery.

METHODS

In a retrospective review over a 6-month period, obese children, 2-18 years of age undergoing surgery were identified. Multivariate mixed-effects regression was used to compare PACU length of stay (LOS) need for opioid analgesia, and hospital admission between moderately and severely obese patients.

RESULTS

There were 1324 records selected for inclusion. PACU LOS did not significantly differ between moderately obese (50 ± 36 min) and severely obese patients (55 ± 38 min). There were no differences between moderately and severely obese patients in use of opioids in the PACU. Yet, severely obese patients were more likely to require inpatient admission than moderately obese patients.

CONCLUSIONS

The duration of PACU stay still averaged less than 1 h in our cohort, suggesting that the majority of these patients can be cared for safely in the outpatient setting. Future studies should focus on identifying the co-morbid conditions that may prolong postoperative PACU stay or result in unplanned hospital admission in moderately and severely obese patients. Our preliminary data suggest that these factors may include a younger age and the complexity or duration of the surgical procedure.

Obesity and its effects on pediatric supracondylar humeral fractures

BACKGROUND

This study evaluates the effects of childhood obesity on fracture complexity and associated injuries in pediatric supracondylar humeral fractures.

METHODS

A billing query identified all patients who were two to eleven years of age and had undergone operative treatment for extension-type supracondylar humeral fractures over a 12.5-year period. Records were reviewed for demographic data, body mass index percentile, and injury data. Complex fractures were defined as type-3 supracondylar humeral fractures, supracondylar humeral fractures with intercondylar extension, or supracondylar humeral fractures with ipsilateral upper-extremity fractures. Logistic regression analyses were used to test relationships among body mass index subgroups, fracture complexity, elbow motion, preoperative and postoperative neurovascular status, and complications.

RESULTS

Three hundred and fifty-four patients met our inclusion criteria. Forty-one children were underweight (BMI in the <5th percentile), 182 were normal weight (BMI in the 5th to 85th percentile), sixty-three were overweight (BMI in the >85th to 95th percentile), and sixty-eight were obese (BMI in the >95th percentile). There were 149 patients, eleven of whom were obese, with isolated type-2 fractures and 205 patients, fifty-seven of whom were obese, with complex fractures. Thirty-two patients had preoperative nerve palsies and twenty-eight patients had postoperative nerve palsies. Using logistic regression, obesity was associated with complex fractures (odds ratio, 9.19 [95% confidence interval, 4.25 to 19.92]; p < 0.001), preoperative nerve palsies (odds ratio, 2.69 [95% confidence interval, 1.15 to 6.29]; p = 0.02), postoperative nerve palsies (odds ratio, 7.69 [95% confidence interval, 2.66 to 22.31]; p < 0.001), and postoperative complications (odds ratio, 4.03 [95% confidence interval, 1.72 to 9.46]; p < 0.001). Additionally, obese patients were more likely to sustain complex fractures from a fall on an outstretched hand than normal-weight patients (odds ratio, 13.00 [95% confidence interval, 3.44 to 49.19]; p < 0.001).

CONCLUSIONS

Obesity is associated with more complex supracondylar humeral fractures, preoperative and postoperative nerve palsies, and postoperative complications. To our knowledge, this study is the first to assess the implications of obesity on supracondylar humeral fracture complexity and associated injuries and it validates public health efforts in combating childhood obesity.

Appendicitis in obese children

During the past two decades, the incidence of childhood obesity has increased at alarming rates throughout the world. Obesity is associated with a variety of physiological changes that may impair a patient's response to surgery. With the rising rates of childhood obesity, pediatric surgeons must appreciate differences in the management and outcomes of these patients. Difficult physical examination, elevated inflammatory blood markers, and negative influence of obesity on the detection rate of the appendix on ultrasound have been reported causing diagnostic challenging of appendicitis in obese children. Moreover, obesity is associated with longer hospital stay and higher morbidity and minimal invasive techniques' superior outcomes over open technique in children undergoing appendectomy.

Effects of obesity on pediatric fracture care and management

Obese children have a theoretically increased risk of sustaining an extremity fracture because of potential variations in their bone mineral density, serum leptin levels, and altered balance and gait. Trauma databases suggest an increased rate of extremity fractures in obese children and adolescents involved in polytrauma compared with nonobese children and adolescents. Anesthetic and other perioperative concerns for obese pediatric trauma patients undergoing surgery include higher baseline blood pressures, increased rates of asthma, and obstructive sleep apnea. A child's weight must be considered when choosing the type of implant for fixation of pediatric femoral fractures. Fracture prevention strategies in obese pediatric patients consist of ensuring properly sized safety gear for both motor vehicles and sporting activities and implementing structured weight-loss programs.

Incidence of perioperative adverse events in obese children undergoing elective general surgery

BACKGROUND

A worldwide increase in the prevalence of obesity has been observed in both developed and developing countries. Few studies have addressed the anaesthetic or perioperative implications of childhood obesity.

METHODS

Children aged 2-16 yr undergoing general surgery were classified using age- and sex-adjusted BMI. Patient characteristic, co-morbidity, and perioperative data were collected to ascertain the risks associated with overweight and obese children.

RESULTS

We enrolled 1465 subjects in our study, of which 154 (10.5%) were classified as obese and a further 223 (15.2%) as overweight. After adjusting for age, we identified increased rates of arterial haemoglobin desaturation, difficult mask ventilation, airway obstruction, and bronchospasm in obese children. The relative risk (RR) of adverse respiratory events was higher among obese subjects than non-obese subjects and higher in younger age groups. Controlling for age, adjusted-RR (confidence interval) was 1.49 (1.2-1.86). There was a significant association between obesity and asthma with a higher odds ratio (OR) in younger age groups controlling for age: adjusted-OR=1.8 (1.15-2.82). A significant association was detected between obesity and sleep apnoea controlling for age: adjusted-OR=4.03 (2.37-6.8).

CONCLUSIONS

These results suggest an increased incidence of perioperative adverse respiratory events in obese children, especially at younger ages.

Pharmacokinetics and Drug Dosing in Obese Children

OBJECTIVES

To review pharmacokinetics in obese children and to provide medication dosing recommendations.

METHODS

EMBASE, MEDLINE, and International Pharmaceutical Abstracts databases were searched using the following terms: obesity, morbid obesity, overweight, pharmacokinetics, drug, dose, kidney function test, creatinine, pediatric, and child.

RESULTS

We identified 10 studies in which the authors examined drug dosing or pharmacokinetics for obese children. No information was found for drug absorption or metabolism. Obese children have a higher percent fat mass and a lower percent lean mass compared with normal-weight children. Therefore, in obese children, the volume of distribution of lipophilic drugs is most likely higher, and that of hydrophilic drugs is most likely lower, than in normal-weight children. Serum creatinine concentrations are higher in obese than normal-weight children. Total body weight is an appropriate size descriptor for calculating doses of antineoplastics, cefazolin, and succinylcholine in obese children. Initial tobramycin doses may be determined using an adjusted body weight, although using total body weight in the context of monitoring serum tobramycin concentrations would also be an appropriate strategy. We found no information for any of the opioids; antibiotics such as penicillins, carbapenems, vancomycin, and linezolid; antifungals; cardiac drugs such as digoxin and amiodarone; corticosteroids; benzodiazepines; and anticonvulsants. In particular, we found no information about medications that are widely distributed to adipose tissue or that can accumulate there.

CONCLUSIONS

The available data are limited because of the small numbers of participating children, study design, or both. The number and type of drugs that have been studied limit our understanding of the pharmacokinetics in obese children. In the absence of dosing information for obese children, it is important to consider the nature and severity of a child's illness, comorbidities, organ function, and side effects and physiochemical properties of the drug. Extrapolating from available adult data is possible, as long as practitioners consider the effects of growth and development on the pharmacokinetics relevant to the child's age.

Childhood body mass index and perioperative complications

BACKGROUND

Our aim was to describe the incidence of quality assurance events between overweight/obese and normal weight children.

METHODS

This is a retrospective review of the quality assurance database of the Mott Children's Hospital, University of Michigan for the period January 2000 to December 2004. Using directly measured height and weight, we computed the body mass index (BMI) in 6094 children. Overweight and obesity were defined using age and gender-specific cut off according to the National Center for Health Statistics (NCHS)/Centers for Disease Control and Prevention (CDC) (2000) growth charts. Frequency of quality assurance events were compared between normal weight, overweight, and obese children.

RESULTS

There were 3359 males (55.1%) and 2735 females (44.9%). The mean age for the entire population was 11.9 +/- 5.2 while the mean BMI was 21.6 +/- 6.7 kg x m(-2). The overall prevalence of overweight and obesity was 31.6%. Obesity was more prevalent in boys than girls (P = 0.016). Preoperative diagnoses of hypertension, type II diabetes, and bronchial asthma were more common in overweight and obese than normal weight children (P = 0.0001 for hypertension, P = 0.001 for diabetes and P = 0.014 for bronchial asthma). Difficult airway, upper airway obstruction in the postanesthesia care unit (PACU) and PACU stay longer than 3 h and need for two or more antiemetics were more common in overweight and obese than normal weight children (P = 0.001). There was no significant difference in the incidence of unplanned hospital admission following an outpatient surgical procedure between normal weight and overweight/obese children.

DISCUSSION

Studies on perioperative aspects of childhood overweight and obesity are rare. Our report shows a high prevalence of overweight and obesity in this cohort of pediatric surgical patients. Certain perioperative morbidities are more common in overweight and obese than in normal weight children. There is a need for prospective studies of the impact of childhood overweight and obesity on anesthesia and surgical outcome.

Childhood obesity and anesthetic morbidity

BACKGROUND

Obesity is present in a significant proportion of children presenting for anesthesia. Although it is perceived that obese adults have more frequent complications, the incidence of complications in obese children is unknown. Because of anticipated difficulties with mask ventilation, anesthesia is most frequently induced intravenously in obese adults, whereas inhalation induction is usually preferred in uncooperative children with few visible veins. The purpose of this study was to examine and compare anesthetic related complications in obese children undergoing dental surgery with a similar group of nonobese individuals.

METHODS

The charts of 1133 American Society of Anesthesiology (ASA) physical status I and II children less than 12 years old who underwent general anesthesia for dental outpatient procedures in 2003 were retrospectively examined for patient height, weight, preoperative evaluation, anesthetic course and postoperative course. Body mass index was calculated and compared with international normative data to identify those children who were obese. Method of induction and perioperative complications were noted.

RESULTS

A total of 100 obese and 1033 nonobese children were identified. Demographically the two groups were comparable. Inhalation induction was used in the vast majority of obese (99%) and nonobese (99.7%) patients. Overall complication rate was low. Minor respiratory complications were more frequently noted in the obese group. These consisted primarily of a higher incidence of intraoperative oxygen desaturation (2% vs 0.19%) and higher requirements for unexpected overnight hospitalization (2% vs 0.19%). The only complication related directly to inhalation induction was noted in a nonobese child who vomited and aspirated on induction.

CONCLUSIONS

Our study demonstrated a small increase in minor respiratory complications in obese children who underwent anesthesia. Inhalation induction was not associated with an increase in adverse events in this population.

Ambulatory anesthesia and the lack of consensus among Canadian pediatric anesthesiologists: a survey

BACKGROUND

The purpose of this study was to assess the current selection criteria for outpatient surgery in children among Canadian pediatric anesthesiologists.

METHODS

A survey specifying 20 different medical situations was sent to 120 members of the Canadian Pediatric Anesthesia Society. Members were asked to indicate if they agreed or refused to provide anesthesia for children with one or more clinical condition or symptoms. Consensus was defined as a >70% majority opinion.

RESULTS

Sixty-four pediatric anesthesiologists replied (53.3%). For 13 conditions there was no consensus among members. Seven scenarios resulted in a consensus of either providing or not providing anesthesia in an outpatient setting. The majority of members would agree to provide anesthesia for the following scenarios: (i) an asymptomatic child with recurrent otitis media, rectal temperature of 38 degrees C; (ii) the same child with chronic nasal discharge for bilateral myringotomy and tube placement; (iii) an asymptomatic child with sickle-cell disease (SCD) for cast change; (iv) an asymptomatic child with asthma and fever for bilateral myringotomy and tube placement (BMT); (v) a morbidly obese child with congested nose for BMT; and (vi) a child with well controlled insulin dependent diabetes mellitus for magnetic resonance imaging (MRI). Most members would refuse to provide outpatient anesthesia in an asymptomatic child with SCD for tonsillectomy.

CONCLUSION

Further studies are needed to establish evidence-based medicine to support guidelines that would allow one to select children safely for ambulatory surgery.

Anesthesia for Pediatric Obesity

This article discusses the unique anesthetic implications of obesity, with an emphasis on children and adolescents. It also touches on the issues surrounding bariatric surgery in the morbidly obese adolescent population. Adolescent bariatric surgery is moving to the forefront as a treatment modality because weight-loss programs alone are not keeping pace with the growth of the problem. Bariatric surgery offers the potential to achieve the weight reductions necessary to reverse the debilitating and costly comorbidities of obesity.

[Airways and respiratory function in obese patients. Anaesthetic and intensive care aspects and recommendations]

In obese patients, perioperative pulmonary complications have an increased frequency and are associated with higher morbidity and mortality compared with non-obese patients. The management of surgical procedures in these patients is a challenge for the anaesthetist. Knowledge of pathophysiological and pharmacological aspects of the obese patients' condition is essential for their care during preoperative assessment, intra-operative management and, if necessary, postoperative intensive care. Special information on airway and lung protection as well as cases involving laparoscopic surgery, obstetric and paediatric anaesthesia in obese patients are also discussed.

Childhood obesity

There has been much public debate over the increasing global problem of obesity. The rise in obesity is not just confined to the adult population, childhood obesity is also on the increase. This article will highlight some of the issues contributing to the recent rise in childhood obesity and its associated health consequences. As healthcare professionals it is essential that we identify how the health-related factors of childhood obesity impact upon the care given in the perioperative environment.