Childhood obesity and anesthetic morbidity

The Impact of Obesity on Perioperative Outcomes for Children Undergoing Appendectomy for Acute Appendicitis: A Systematic Review

Today, the prevalence of obesity in the pediatric population has increased dramatically. Acute appendicitis (AA) is the most common surgical condition among pediatric patients. We aimed to investigate the impact of obesity on postoperative outcomes in terms of operative time (OT), length of stay (LOS), surgical site infection (SSI), overall complications, adverse events, and mortality in children undergoing appendectomy for acute appendicitis. An extensive search of the literature in PubMed and Google Scholar was conducted to evaluate the outcomes of normal weight (NW), overweight (OW), and obese (OB) children who underwent appendectomy. Although no statistically significant differences were noted in perioperative outcomes and overall postoperative complications between OW/OB and NW children in the majority of the included studies, prolonged OT and LOS and SSI were found in some studies. Moreover, no differences in terms of readmissions and ED visits were recorded. We conclude that the impact of obesity on postoperative outcomes for children undergoing appendectomy for AA is unclear, and, therefore, no safe conclusions can be drawn with the currently available data. Due to the lack of high-quality studies, further research is required to optimize the surgical approach and prevent unwarranted complications.

Tibial shaft fractures in children: flexible intramedullary nailing in growing children especially weighing 50 kg (110 lbs) or more

Currently the gold standard in surgical treatment of displaced tibial shaft fractures in children with open growth cartilage is elastic stable intramedullary nailing (ESIN). The purpose of this study is the analysis of indications, complications, and duration of treatment using intramedullary flexible nails in children who are still growing but especially weighing 50 kg or more. Hospital records from 2017 to 2020 were retrospectively reviewed to identify the children from 4 to 17 years of age with displaced tibial shaft fractures admitted to the hospital. Only children with open growth cartilage, with a minimum of 6 months of follow-up and complete clinical data, were included. Studies of 91 children xwere analyzed. The average patient age at the time of the injury was 10.88 ± 2.82 years. In the entire group, 31.9% children weighed 50 kg or more, and 68.1% of the children were below this weight. All children were treated using ESIN. The mean time to nail removal was 8.4 ± 4.09 months in the whole group of children stabilized with ESIN. There were no differences in the two groups depending on the weight ( P = 0.637). Only two adverse events were observed. This study demonstrates that the use of ESIN in displaced tibial shaft fractures in growing children weighing 50 kg or more is acceptable and safe. The discussion to be made is whether it is still an acceptable method of treatment for this type of fracture due to the progressive obesity epidemic in children and adolescents.

Perioperative respiratory adverse events during ambulatory anesthesia in obese children

Obesity is one of the most common clinical conditions in the pediatric population with an increasing prevalence ranging from 20 to 30% worldwide. It is well known that during ambulatory anesthesia, obese children are more prone to develop perioperative respiratory adverse events (PRAEs) associated with obesity. To avoid or at least minimize these adverse effects, a thorough preoperative assessment should be undertaken as well as consideration of specific anesthetic approaches such as preoxygenation before induction of anesthesia and optimizing drug dosing. The use of short-acting opioid and nonopioid analgesics and the frequent implementation of regional anesthesia should also be included. Noninvasive airway management, protective mechanical ventilation, and complete reversion of neuromuscular blockade and awake extubation also proved to be beneficial in preventing PRAEs. During the postoperative period, continuous monitoring of oxygenation and ventilation is mandatory in obese children. In the current review, we sought to provide recommendations that might help to reduce the severity of perioperative respiratory adverse events in obese children, which could be of particular importance for reducing the rate of unplanned hospitalizations and ultimately improving the overall postoperative recovery.

Severe obesity in children as an independent risk factor for perioperative respiratory adverse events during anaesthesia for minor non-airway surgery, a retrospective observational study

Purpose:

The purpose of this article is to quantify grades of obesity and their independent effects on perioperative adverse events in children having ambulatory minor non-airway surgery.

Methods:

After obtaining ethics committee approval, we selected every tenth child aged 2 to 16 years who was identified as having been a day case between January 2012 and December 2014. Weight groups were defined based on age- and gender-specific body mass index (BMI) cutoff points. A sample size of 1102 was calculated to demonstrate a three-fold increase in the primary outcome measure, perioperative respiratory-airway adverse events, among obese children, with a power of 80% and an alpha error of 5%. Chi-squared and Fisher exact tests were used to compare proportions, and independent sample t tests were used to compare means.

Results:

Severely obese children had a significantly higher incidence of perioperative respiratory-airway adverse events when compared to normal-weight children despite no difference in respiratory and other comorbidity. Obese children had higher prevalence of overall medical comorbidities and obstructive sleep apnoea when compared to normal-weight children and there was no significant difference in the incidence of perioperative respiratory-airway adverse events and other outcome measures between obese and normal-weight children.

Conclusions and recommendations:

Severely obese children have a higher risk of perioperative respiratory-airway adverse events even during minor non-airway surgery despite absence of medical comorbidities. We recommend the use of age- and sex- specific BMI cutoffs or BMI percentile charts to identify children who are severely obese to anticipate and prevent major respiratory adverse events.

Characterizing the spectrum of body mass index associated with severe postoperative pulmonary complications in children

PURPOSE

While high body mass index (BMI) is a recognized risk factor for pulmonary complications in adults, its importance as a risk factor for complications following pediatric surgery is poorly described. We evaluated the association between BMI and severe pediatric perioperative pulmonary complications (PPCs).

METHODS

In this retrospective cohort study, we evaluated pediatric patients (aged 2-17 years) undergoing elective procedures in the 2015 Pediatric National Surgical Quality Improvement Program (NSQIP-P). Severe PPCs were defined as either pneumonia/reintubation within 3 days of surgery, or pneumonia/reintubation as an index complication within 7 days. Univariate and multivariable logistic regression analyses adjusting for patient factors and surgical case-mix tested associations between BMI class-using the Centers for Disease Control age- and sex-dependent BMI percentiles-and severe PPCs.

RESULTS

Among 40,949 patients, BMI class was distributed as follows: 2740 (6.7%) were underweight, 23,630 (57.7%) normal weight, 6161 (15.0%) overweight, and 8418 (20.6%) obese. Overweight BMI class was not associated with PPCs in univariate analyses, but became statistically significant after adjustment [OR 1.84 (95% CI 1.07-3.15), p = 0.03], and persisted across multiple adjustment approaches. Neither underweight [OR 1.01 (95% CI 0.53-1.94), p = 0.97] nor obesity [OR 1.10 (95% CI 0.63-1.94), p = 0.73] were associated with PPCs after adjustment.

CONCLUSION

Overweight pediatric patients have an elevated, previously underappreciated risk of severe PPCs. Contrary to prior studies, the present study found no greater risk in obese children, perhaps due to bias, confounding, or practice migration from "availability bias". Findings from the present study, taken with prior work describing pulmonary risks of obesity, suggest that both obese and overweight children may be evaluated for tailored perioperative care to improve outcomes.

Pediatric tibia and femur fractures in patients weighing more than 50 kg (110 lb): mini-review on current treatment options and outcome

The main objective of this paper is to review the current literature on treatment of tibial and femur fractures in children and adolescents guided by body weight in patients weighing 50 kg (110 lb) or more. A secondary aim of this mini-review was to determine, as per literature review, whether weight  > 50 kg (110 lb) is an identifiable factor associated with increased complication rate. A search of the PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews databases from 1954 to September 2017 was performed to identify papers related to pediatric tibia and femur fractures in children weighing more than 50 kg (110 lb). Abstracts were screened, and relevant full-text articles were retrieved for further review. Reference sections of identified papers were also screened to identify further literature. All levels of evidence were included. Overall, seven full-text articles dealing with pediatric tibia or femur fractures in patients weighing more than 50 kg (110 lb), and one article reporting on both femur and tibia fractures in this patients' population, have been identified (n = 8 full-text article included). The articles reviewed a total of 679 children. In particular, 48/438 femur shaft fractures (mean weight: 51.7 kg or 113.9 lb) and 91/241 tibia fractures (mean weight: 53.3 kg or 117.5 lb) met the inclusion criteria. The overall rate of complications was 27.9%. In particular, the rate of complication was 51.7 and 29.6% in children with femur and tibia fracture weighing more than 50 kg (110 lb), respectively (p < 0.05). Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for displaced tibia and femur shaft fractures in children between six and 12-15 years of age. Unstable fracture pattern, higher age and higher weight have been reported as potential risk factors associated with poor outcomes in children and adolescents treated with ESIN for displaced long bone fractures of the lower extremity, in particular femur shaft fractures. Despite these findings, data reporting exclusively on ESIN-treated long bone fractures in children weighing 50 kg (110 lb) or more remain scant.

Peri-operative management of overweight and obese children and adolescents

Obesity has become endemic, even in children. Systemic complications associated with obesity include metabolic syndrome, cardiovascular disease, and respiratory compromise. These comorbidities require adequate investigation, targeted optimisation, and, if surgery is required, specific management during the peri-operative period. Specific peri-operative strategies should be used for paediatric patients who are overweight or obese to prevent postoperative complications, and optimising the respiratory function during surgery is particularly crucial. This Review aims to provide up-to-date information on peri-operative management for physicians who are caring for children and adolescents (usually younger than 18 years) who are overweight or obese undergoing surgery, including bariatric surgery. We have particularly focussed on the physiological consequences of obesity-namely, obstructive sleep apnoea, respiratory compromise, and pharmacological considerations.

The Musculoskeletal Aspects of Obesity in Neuromuscular Conditions

Obesity is a common problem in children and adolescents with neuromuscular disease. The available literature on obesity in cerebral palsy, spina bifida, and Duchenne muscular dystrophy as it relates to orthopedic treatment is reviewed, including the demographics and measurement of obesity as well as the mechanisms of obesity in these individuals. In addition, the effect of obesity on function, patient evaluation, and orthopedic treatment are reviewed.

Association of BMI With Propofol Dosing and Adverse Events in Children With Cancer Undergoing Procedural Sedation

OBJECTIVES

Obesity increases the risk of complications during pediatric procedural sedation. The risk of being underweight has not been evaluated in this arena. We therefore investigated the association of BMI with sedation dosing and adverse events in children across a range of BMIs.

METHODS

A total of 1976 patients ages 2 to 21 years old with oncologic diagnoses underwent lumbar punctures and/or bone marrow aspirations. All children received a standard adjunctive dose of ketamine before sedation with propofol. Weight categories were stratified by BMI percentile: underweight <5%, normal weight 5% to 85%, overweight >85%, and obese >95%. Dosing and adverse events (hypoxia, apnea, bradycardia, or hypotension) were reviewed.

RESULTS

There were no differences in propofol dosing for procedural sedation between patients who were normal weight and underweight. However, children who were overweight and those who were obese used less propofol compared with children who were normal weight (P < .01). Children who were underweight had a higher proportion of adverse events overall relative to those children of normal weight (P < .001). In contrast, there was not an increase in adverse events for patients who were overweight and obese.

CONCLUSIONS

Children who are overweight and children with obesity who require deep sedation can undergo successful sedation with lower propofol dosing relative to children of a normal weight. This dosing strategy may help to mitigate the risks associated with sedating patients who are obese. Notably, children who were underweight had an increased rate of complications despite receiving an equal amount of sedation compared with patients who were normal weight. This should alert the clinicians to the risks associated with sedating children who are underweight.

Desaturation in procedural sedation for children with long bone fractures: Does weight status matter?

INTRODUCTION

Childhood obesity remains a serious problem in the United States. Significant associated adverse incidents have been reported with sedation of children with obesity, namely hypoxemia. The objective of our study was to determine if overweight and obesity were associated with increased desaturations during procedural sedation compared with patients of healthy weight.

METHODS

This was a single-center retrospective chart review of data from a three-year period of patient's age 2-17years. Of the 1700 charts reviewed 823 of these patients received procedural sedation and met the study inclusion criteria. Weight status was classified based on age and gender specific body mass index (BMI) percentiles: underweight, healthy weight, overweight, obese.

RESULTS

Among all weight categories there was no statistical significance, however children with obesity had greater desaturation rates (9.9%) compared with children of underweight, healthy weight, or overweight combined (5.4%), χ²=4.46, p=0.035.

DISCUSSION

The results indicate that children with obesity are almost twice as likely to have a desaturation related to procedural sedation compared with children of other weight status. Providers should be aware that children with obesity may be more likely to desaturate than other children, and therefore be skilled at recognizing this.

Effect of body mass index percentile on pediatric gastrointestinal surgery outcomes

BACKGROUND/PURPOSE

Pediatric obesity is an important public health concern, yet its effect on surgical outcomes is poorly understood. The purpose of this study was to determine if age and gender-specific body mass index (BMI) percentile influences complications and hospital resource utilization following pediatric gastrointestinal surgeries.

METHODS

Patients aged ≥2 to <18years who underwent appendectomy or other gastrointestinal operations were identified in the 2012-2013 Pediatric National Surgical Quality Improvement Program datasets. Age- and gender-specific pediatric BMI percentiles were calculated. Patients who underwent appendectomy (n=9606) and those undergoing all other intestinal operations (n=2664) were evaluated as separate cohorts.

RESULTS

In the appendectomy cohort, frequency of any complication increased with BMI category (normal weight 4.5%, overweight 5.3%, obese 5.7%, morbidly obese 7.3%, overall 5.0%, p=0.014). In multivariate analysis, there was a quadratic association between BMI percentile and increased frequency of superficial incisional infection, unplanned tracheal intubation, and longer operative duration. In the intestinal surgery cohort, BMI percentile was not a predictor of any individual complication or any measure of hospital utilization.

CONCLUSIONS

Age- and gender-specific BMI percentile was associated with increased risk of complications and longer operative duration in patients undergoing appendectomy but not other intestinal operations.

The influence of underweight and obesity on the diagnosis and treatment of appendicitis in children

PURPOSE

The impact of lower body mass index (BMI) on appendicitis has never been addressed. We investigated whether different BMIs affect the diagnosis and treatment of appendicitis in children.

METHODS

The correlation between BMI and diagnosis accuracy and treatment quality was evaluated by retrospective analysis of 457 children diagnosed with appendicitis. Based on BMI percentiles, patients were classified as either underweight (n = 36), normal weight (n = 346), overweight (n = 59), or obese (n = 16). Diagnosis accuracy was measured by negative appendectomy rate, perforation rate, and number of consultations. Treatment quality was measured by complication rate and length of hospital stay.

RESULTS

Underweight patients had the highest negative appendectomy (OR 3.00, P = 0.008) and complication (OR 2.75, P = 0.041) rate. BMI did not influence perforation rate or number of consultations. Both underweight and obese patients stayed in the hospital longer than normal weight patients (regression coefficient 2.34, P = 0.001, and regression coefficient 9.40, P < 0.001, respectively). Furthermore, in obese patients, the hospital stay after open appendectomy was prolonged compared to laparoscopic appendectomy (P < 0.001). No such differences were observed in patients with lower BMI.

CONCLUSIONS

Underweight children are misdiagnosed more often, stay in hospital longer, and experience more postoperative complications than children of normal weight. Obesity is associated with longer hospital stays. Laparoscopic appendectomy might shorten the length of hospital stays in these patients. We conclude that in addition to obesity, underweight should also be considered a risk factor for children with appendicitis.

The impact of obesity on pediatric procedural sedation-related outcomes: results from the Pediatric Sedation Research Consortium

OBJECTIVES

To evaluate the impact of obesity on adverse events and required interventions during pediatric procedural sedation.

METHODS

The Pediatric Sedation Research Consortium database of prospectively collected procedural sedation encounters was queried to identify patients for whom body mass index (BMI) could be calculated. Obesity was defined as BMI ≥95th percentile for age and gender. Sedation-related outcomes, adverse events, and therapeutic interventions were compared between obese and nonobese patients.

RESULTS

For analysis, 28,792 records were eligible. A total of 5,153 patients (17.9%) were obese; they were predominantly male and older and had a higher median American Society of Anesthesiologists Physical Status classification (P < 0.001). Total adverse events were more common in obese patients (odds ratio [OR] 1.49, 95% confidence interval [1.31, 1.70]). Respiratory events (airway obstruction OR 1.94 [1.54, 2.44], oxygen desaturation OR 1.99 [1.50, 2.63], secretions OR 1.48 [1.01, 2.15], laryngospasm OR 2.30 [1.30, 4.05]), inability to complete the associated procedure (OR 1.96 [1.16, 3.30]), and prolonged recovery (OR 2.66 [1.26, 5.59]) were increased in obese patients. Obese patients more frequently required airway intervention including repositioning, suctioning, jaw thrust, airway adjuncts, and bag-valve-mask ventilation. Multivariate regression analysis demonstrated obesity to be independently associated with minor and moderate but not major adverse events.

CONCLUSIONS

Obesity is an independent risk factor for adverse respiratory events during procedural sedation and is associated with an increased frequency of airway interventions, suggesting that additional vigilance and expertise are required when sedating these patients.

Does obesity prolong anesthesia in children undergoing common ENT surgery?

OBJECTIVES

To report the epidemiology of obesity in a pediatric surgical population and determine whether obesity is a risk factor for longer anesthesia duration.

BACKGROUND

Childhood obesity is a significant public health problem in the United States. Epidemiologic studies on pediatric surgical populations have been limited to states with very high prevalence of adult obesity (Michigan, Texas). Data from other states and more recent data since 2006 are unavailable.

METHODS

We examined anesthesia records for surgical patients age 2-18 years at Columbia University Medical Center from January 2009 to December 2010. Patients undergoing bariatric surgery or those with records missing preoperative height or weight data were excluded. Body mass index (BMI) was calculated as weight (kg)/height (m(2) ). BMI ≥95th percentile according to national growth charts were considered obese.

RESULTS

We reviewed 9522 patients of which 1639 were obese (17.2%). The sex-age category interaction on obesity was not significant using logistic regression (P = 0.11). Among surgical groups, the otolaryngology (ENT) cohort had the highest obesity rate (21.7%, 360/1656). Obese children who had tonsillectomy, adenoidectomy, or both did not have a prolonged anesthetic (P = 0.33) or surgical duration (P = 0.61) compared with nonobese children, adjusting for surgeon, season, surgical procedure code, and ASA status.

CONCLUSION

Children presenting for surgery, particularly the ENT cohort, have a high prevalence of obesity. Obese and nonobese children who had tonsillectomy, adenoidectomy, or both had comparable durations of anesthesia. Therefore, obesity did not lead to longer anesthetic duration.

Pediatric obesity and safety in inpatient settings: a systematic literature review

OBJECTIVE

Pediatric obesity affects more than 16% of American children and is associated with worse outcomes in hospitalized patients. A systematic literature review was performed to identify studies of adverse care events affecting obese pediatric patients in the emergency room, operating room, or inpatient wards.

EVIDENCE REVIEW

We systematically searched Medline for articles published from 1970 to 2013 regarding obesity and patient safety events in pediatric acute care settings. We determined the study design, number of patients studied, definition and prevalence of obesity, the relevant acute care setting, the specific association with obesity addressed, and the results of each study.

RESULTS AND CONCLUSION

Thirty-four studies documented both procedural complications and issues with general hospital care. Most were retrospective and focused on surgery or anesthesia. Obese patients may have increased risk for a variety of adverse events. Further study could improve institutional patient safety guidelines to enhance care for obese children.

Respiratory complications in the pediatric postanesthesia care unit

This article focuses on common respiratory complications in the postanesthesia care unit (PACU). Approximately 1 in 10 children present with respiratory complications in the PACU. The article highlights risk factors and at-risk populations. The physiologic and pathophysiologic background and causes for respiratory complications in the PACU are explained and suggestions given for an optimization of the anesthesia management in the perioperative period. Furthermore, the recognition, prevention, and treatment of these complications in the PACU are discussed.

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.

Perioperative outcomes of severely obese children undergoing tonsillectomy

BACKGROUND

Sleep-disordered breathing, a common condition in obese children, is a frequent indication for tonsillectomy.

OBJECTIVE

The purpose of this study was to examine the association between obesity and perioperative complications in children undergoing tonsillectomy.

METHODS/MATERIALS

A sample of 100 severely obese children (body mass index for age [BMIA], ≥ 98 th percentile) between ages 2 and 18 years who underwent tonsillectomy at Mayo Clinic Rochester was randomly selected. Each severely obese child was age (± 2 years) and sex matched to two normal weight children (BMIA between 25th and 75th percentiles) undergoing tonsillectomy during the study period, and their medical records were reviewed.

RESULTS

Severely obese children had a significantly higher incidence of comorbid conditions including respiratory disorders and severe systemic disorders or syndromes. Severely obese children had a higher frequency of perioperative airway complications (15.0% vs 2.0%). From posthoc analyses, severe obesity remained a significant risk factor for perioperative adverse events after adjusting for the presence of severe systemic disorders or syndromes (OR 8.8; 95% CI 2.8-27.5, P < 0.001) and also after adjusting for preoperative respiratory disorders (OR 7.7; 95% CI 2.5-24.3, P < 0.001). When children with planned admissions were excluded from the analysis, severe obesity was associated with an increased rate of unplanned hospital admission (OR 3.80, 95% CI 1.8-7.9, P < 0.001).

CONCLUSIONS

Severe obesity in children undergoing tonsillectomy is independently associated with an increased risk of perioperative complications. It appears that both severe obesity and systemic comorbid condition contribute to higher proportions of inpatient tonsillectomies performed in our institution.

Do children with high body mass indices have a higher incidence of emesis when undergoing ketamine sedation?

OBJECTIVES

The objective of this study was to determine if overweight children are more likely than normal-weight children to require ondansetron when undergoing ketamine sedation in a pediatric emergency department.

METHODS

Patients between the ages of 2 and 18 years with an American Society of Anesthesiologists classification of I or II who underwent intravenous procedural sedation with ketamine with or without midazolam for uncomplicated forearm fracture reduction in an urban pediatric emergency department during the year 2007 were included. A review of sedation records was conducted for each visit. Data collected included demographics, sedation time, and doses of medications administered. Body mass index (BMI) was calculated using an estimated height for the 50th percentile for age and sex. In 2007, all patients underwent procedural sedation per protocol. Per protocol, patients did not prophylactically receive ondansetron during procedural sedations.

RESULTS

During the study period, 141 patients were identified who met inclusion criteria. Of these, 110 had an estimated BMI less than 25 kg/m; 31 had an estimated BMI of 25 kg/m or greater. Ten patients (7.1%) received ondansetron. Patients in the high-BMI group were more likely to have received ondansetron than those in the normal-BMI group (16.1% vs 4.5%, P = 0.04).

CONCLUSIONS

Our data suggest that pediatric patients with high BMIs are at greater risk for nausea or emesis during ketamine sedation. Clinicians should consider prophylactic administration of ondansetron to this group of patients before performing ketamine sedation.

Impact of obesity on orthopaedics

The prevalence of obesity among children and adults is increasing worldwide. There are substantial health risks and financial costs associated with the obesity epidemic that impact the practice of orthopaedic surgery. Patients with increased body mass index are more prone to sustaining distal extremity injuries than are those with a normal body mass index. Obese individuals are more likely than nonobese individuals to seek treatment for osteoarthritis of the knee.

Improved outcomes in paediatric anaesthesia: contributing factors

PURPOSE

To discuss developments in paediatric anaesthesia and explore the factors which have contributed to improved anaesthetic-related patient outcomes.

METHODS

Narrative review of findings in the literature retrieved from MEDLINE/Pubmed and manual search.

RESULTS

Adverse perioperative outcomes related to anaesthesia have been extensively debated over the past few decades, with studies implicating factors such as major human error and equipment failure. Case series and event registries have enlightened physicians on sources of error and patient risk factors such as extremes of age, comorbidity and emergent circumstances. Anaesthetic-related deaths in children fell from 6.4 per 10,000 anaesthetics in the early 1950s to as low as 0.1 per 10,000 anaesthetics by the end of the century. Advances in anaesthetic agents, techniques, monitoring technologies and training programmes in paediatric anaesthesia play a vital role in driving this downward trend.

CONCLUSION

Despite substantial progress, there is still much room for improvement in areas such as adverse-event reporting, anaesthetic-related risk and late neurocognitive outcomes. Systematic reviews comparing paediatric patient outcomes after neuroaxial block versus general anaesthesia are currently unavailable. The future of paediatric anaesthesia will most likely be influenced by much-needed large prospective studies, which can provide further insight into patient safety and service delivery.

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.

Anaesthetic considerations for the obese child

The prevalence of obesity in the paediatric population is increasing worldwide. As a result, more and more children will present for anaesthetic care for surgery and other procedures. This review aims to provide some recent information regarding the anaesthetic management of the obese child. Unfortunately, there is little evidence on which to base our clinical care of these children and what information is available is often extrapolated from adult practice. Further prospective studies are required, with careful attention to definitions and terminology, so that populations can be compared and appropriate conclusions drawn.

Anesthetizing the obese child

The prevalence of childhood obesity is increasing. The focus of this review is the special anesthetic considerations regarding the perioperative management of obese children. With obesity the risk of comorbidity such as asthma, obstructive sleep apnea, hypertension, and diabetes increases. The obese child has an increased risk of perioperative complications especially related to airway management and ventilation. There is a significantly increased risk of difficult mask ventilation and perioperative desaturation. Furthermore, obesity has an impact on the pharmacokinetics of most anesthetic drugs. This has important implications on how to estimate the optimal drug dose. This article offers a review of the literature on definition, prevalence and the pathophysiology of childhood obesity and provides suggestions on preanesthetic evaluation, airway management and dosage of the anesthetic drugs in these patients. The authors highlight the need of supplemental studies on various areas of the subject.

Anaesthesia in the obese child

The incidence of childhood obesity ranges today from approximately 8% to 17%, and is an increasing issue in developed and developing countries. This disease will become increasingly significant in paediatric anaesthesia. Obese children not only have anaesthesia-relevant co-existing diseases, that are, asthma and hypertension, but also have a higher incidence of anaesthesia-related complication. This review covers current definition and some epidemiology of childhood obesity. It summarises potential co-morbidities and provides details for preoperative evaluation, anaesthetic management and prevention of perioperative complications.

Pediatric obesity: observed impact in the ambulatory surgery setting

More obese children are presenting for surgery, reflecting an increase in comorbidities requiring surgery or an increased prevalence in the community. The objectives of this study were to determine the prevalence of obesity in our pediatric surgery patient population, detect ethnic disparities amongst this cohort of obese patients and also to determine any increase in pediatric obesity related comorbidities requiring surgery. Day surgery patients between ages 3 and 17 years were prospectively studied over a 3-month period. The proportion of obese children, demographics, and surgical procedures were determined. Of the 1559 patients analyzed, 312 (20%) were obese. Close to half of this subset of children were of Hispanic descent. Adenotonsillectomy was the most common surgery; however, the case distribution of this cohort was similar to our operating room database. Prevalence of pediatric obesity in our day surgery patients therefore reflects that of the community and has not resulted in an increase in related comorbidities requiring surgery. Longitudinal studies to assess the incidence of pediatric obesity related complications will be beneficial.

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.

Single-port appendectomy in obese children: an optimal alternative?

INTRODUCTION

The aim of this study was to evaluate our experience with single-port appendectomy (SPA) in obese children.

METHODS

From January 2003 to June 2009, 94 SPA (65 women and 29 men, mean age of 12.4 years) were performed in children with appendicitis. Sixty-five of these patients were found to have normal weight, whereas 29 were obese. Patients' records were evaluated regarding operative time, intra- and post-operative complications, initiation of oral intake and histopathological findings.

RESULTS

There was no significant difference in operative time between obese and normal weight patients. In the obese group, one wound healing disturbance was documented. In the normal weight group, there were one post-operative bleeding and one wound infection. There was no difference with regards to the introduction of feeds following appendectomy between the groups. Histological examinations revealed 15 normal, 32 acute, 21 phlegmonous, 20 chronic and two perforated cases of appendicitis, three neurogenic appendicopathies and one case of enterobius vermicularis related appendicitis.

CONCLUSIONS

Our results indicate that the advantages of single-port appendectomy in the evaluation of the peritoneal cavity, the minimal rate of intra-operative incidents with this technique and superior cosmetics validate this alternative approach of minimal access appendectomy in obese children.

[Laryngospasm]

BACKGROUND AND OBJECTIVES

Airways management is fundamental for anesthesiologists, especially during induction of anesthesia and after extubation, when laryngeal spasm is more common. The anesthesiologist should know pharyngeal-laryngeal physiology and the risk factors for airways obstruction, since this is a potentially severe complication with a multifactorial etiology that can develop during anesthesia and whose consequences can be catastrophic. A delay in the diagnosis or treatment and its evolution can lead to hypoxemia, acute pulmonary edema, and, eventually, death of the patient. In this context, the objective of this report was to review the measures that should be taken in cases of laryngospasm because adequate oxygenation and ventilation may be compromised in this situation.

CONTENTS

This review article presents the mechanisms of airways management, discussing the most relevant aspects and etiology, pathophysiology, treatment, and prevention of laryngospasm.

CONCLUSIONS

The literature has several recommendations on the treatment or prevention of laryngospasm, but none of them is completely effective. Due to its severity, further studies on measures to prevent this complication are necessary.

Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg

BACKGROUND

Previous studies report that children above the 95th percentile in weight for their age had an increased risk for complications following titanium elastic nailing for femur fractures. The purpose of this study is to examine whether obesity, defined as body mass index (BMI) > 95th percentile, and/or simple weight correlates with an increased rate of complications.

METHODS

The incidence of complications was compared between obese and non-obese patients and also between patients who weighed >/=50 kg and those <50 kg.

RESULTS

The overall complication rate was 23% (16/71). The complication rate was 17% (10/58) for "non-obese" patients and 46% (6/13) for "obese" patients. This difference was statistically significant (P = 0.03). The complication rate was 46% (6/13) in children who weighed >/=50 kg and 17% (10/58) in children who weighed <50 kg. This difference was also statistically significant (P = 0.03).

CONCLUSIONS

This study demonstrates that obesity (BMI > 95th percentile) and weight over 50 kg predispose patients to increased risk of surgical complications when undergoing flexible elastic nailing for femur fractures. Both obese children and children weighing >/=50 kg were two times more likely to have a complication when undergoing this procedure.

Outcomes of pediatric anesthesia

Improvement in anesthesia outcomes has derived from advances in safety science related to equipment, drugs, human factors analysis, professional standardization and organization, subspecialty care, and regionalization. Outcomes of pediatric anesthesia have improved, but universal outcome measures are lacking. Because of the limitations of small numbers, future improvement efforts will necessarily involve multiple disciplines, institutions, and regions, and will require sophisticated systems approaches.