Some Cautionary Tales About Ideal Body Weight Dosing of Anesthetic Medications: It Is Not All That Ideal!

Anesthesia considerations for pediatric metabolic and bariatric surgery

Childhood obesity is a rapidly growing global health issue, linked to significant lifelong morbidity and mortality. Its impact on various organ systems increases perioperative complications. Obesity treatment in children and adolescents involves lifestyle, dietary, and behavioral modifications, as well as pharmacologic interventions that targets hormonal, metabolic, and neurochemical abnormalities. Metabolic and bariatric surgery, proven safe and effective for adults with severe obesity (class 2 or higher), is now being recommended for adolescents. Key anesthetic considerations for these surgeries include preoperative optimization, advanced airway management, targeted ventilation strategies, and opioid-sparing analgesic regimens. Comprehensive presurgical evaluations must address co-morbid conditions such as hypertension, obstructive sleep apnea, asthma, and impaired glycemic control. Preoperative management should also consider the effects of antiobesity medications on gastric emptying and hemodynamic stability. Ventilation strategies should prevent atelectasis while avoiding barotrauma, and drug dosages must be adjusted for altered pharmacokinetics due to increased adipose tissue. Employing enhanced recovery after surgery protocols may reduce perioperative complications, shorten postsurgical stays, and improve outcomes.

Evaluation of age-banded dosing of oral paracetamol in hospitalised children: a retrospective analysis using clinical data in a tertiary paediatric hospital

OBJECTIVE

To evaluate age-banded dosing in paediatric inpatients by determining the proportion of patients whose dose would fall outside the therapeutic range (by weight).

DESIGN

A retrospective observational study. Weight and height measurements and details of hospital admissions were matched from the electronic patient record of a single, tertiary paediatric hospital. Dosage which would be given according to age-banded dosing was then compared with their weight.

PARTICIPANTS

All children admitted to a single tertiary children's hospital aged 3 months to 16 years over a 5-year period. Data were cleaned to remove values likely to be erroneous and filtered to reduce bias due to patients who were admitted on multiple occasions.

OUTCOMES

The main outcome was the proportion of patients who would receive a subtherapeutic or supratherapeutic paracetamol dose if given a dose based on their age. Secondary outcomes were to examine this in children of different ages and to examine the impact of alternative size-based dosing strategies.

RESULTS

100 047 admissions (in 68 310 patients) had a weight documented. If age-banded dosing had been used, a subtherapeutic dose (less than 10 mg/kg) would be given during 19 829 (20%) of the admissions and a supratherapeutic dose (over 18.75 mg/kg, 75 mg/kg/day in four doses) in 4289 (4.3%). The highest risk of a subtherapeutic dose occurred in infants just prior to reaching 6 months of age (83%) and in children just prior to reaching 8 years (66%). The highest risk of a supratherapeutic dose was at 12 years of age (35%).

CONCLUSION

Age-banded dosing is not suitable for an inpatient paediatric population as approximately a quarter of patients receive a dose outside the recommended range of 10.0-18.75 mg/kg.

Developmentally Appropriate Care of Pediatric Patients in the Perioperative Setting

Pediatric patients do not undergo procedures exclusively at pediatric specialty facilities. Many perioperative nurses will care for a pediatric patient at some point in their career. Children and their caregivers often experience elevated levels of anxiety during the perioperative experience. Possessing knowledge of the child's age and developmental stage and using effective communication techniques can decrease this anxiety. This article presents insights into the stages of pediatric cognitive and psychosocial development and special pediatric health care considerations. Approaching and interacting with a child in a manner appropriate for their age and developmental stage can foster a more trusting nurse-child-caregiver relationship and reassure the caregiver that the perioperative team is providing their child with safe, high-quality care. Also included are five hypothetical case studies that illustrate effective communication styles and developmentally appropriate techniques that personnel can apply during the pediatric patient's perioperative experience.

Inherent Dangers of Using Non-US Food and Drug Administration-Approved Substances of Abuse

Use of US Food and Drug Administration-approved substances of abuse has innate risks due to pharmacologic and pharmacokinetic properties of the medications, but the risk when using nonapproved drug products is much greater. Unbeknownst to the user, the dose of active ingredients in substances of abuse can vary substantially between different products because of manufacturing practices or improper storage. Even naturally occurring substances of abuse can have extensive dosage variability because of effects of the growing season and conditions, or differences in harvesting, storage, or manufacture of the finished products. Many illicit substances are adulterated, to make up for intentional underdosing or to enhance the effect of the intended active ingredient. These adulterants can be dangerous and produce direct cardiovascular, neurologic, hematologic, or dermatologic reactions or obscure adverse effects. Finally, an illicit substance can be contaminated or substituted for another one during its manufacture, leading to differences in adverse events, adverse event severity, or the drug interaction profile. Substances can be contaminated with microbes that induce infections or heavy metals that can damage organs or cause cancer. This milieu of undisclosed substances can also induce drug interactions. For reasons that are discussed, individuals who use substances of abuse are at increased risk of morbidity or mortality if they develop coronavirus disease 2019. Health professionals who treat patients with acute, urgent events associated with substances of abuse, or those treating the chronic manifestations of addiction, need to appreciate the complex and variable composition of substances of abuse and their potential health effects.

Pediatric obesity and perioperative medicine

PURPOSE OF REVIEW

Childhood obesity is a public health emergency that has reached a pandemic level and imposed a massive economic burden on healthcare systems. Our objective was to provide an update on (1) challenges of obesity definition and classification in the perioperative setting, (2) challenges of perioperative patient positioning and vascular access, (3) perioperative implications of childhood obesity, (3) anesthetic medication dosing and opioid-sparing techniques in obese children, and (4) research gaps in perioperative childhood obesity research including a call to action.

RECENT FINDINGS

Despite the near axiomatic observation that obesity is a pervasive clinical problem with considerable impact on perioperative health, there have only been a handful of research into the many ramifications of childhood obesity in the perioperative setting. A nuanced understanding of the surgical and anesthetic risks associated with obesity is essential to inform patients' perioperative consultation and their parents' counseling, improve preoperative risk mitigation, and improve patients' rescue process when complications occur.

SUMMARY

Anesthesiologists and surgeons will continue to be confronted with an unprecedented number of obese or overweight children with a high risk of perioperative complications.

Practical Estimation of Ideal Body Weight and Normalized Lean Weight

Simple formulas for estimating ideal body weight (IBW) and normalized lean weight (NLW) are proposed here. The equations are as follows:[Formula: see text][Formula: see text]where W is equal to total patient weight in kilograms and BMI is the body mass index in units of kg/m². The calculated values are equivalent for practical purposes to previously published formulas.

Antimicrobial Dosing in Specific Populations and Novel Clinical Methodologies: Obesity

Obesity and its related comorbidities can negatively influence the outcomes of certain infectious diseases. Specific dosing recommendations are often lacking in the product label for patients with obesity that leads to unclear guidance in practice. Higher rates of therapeutic failure have been reported with some fixed dose antibiotics and pragmatic approaches to dose modification are limited for orally administered agents. For i.v. antimicrobials dosed on weight, alternate body size descriptors (ABSDs) have been used to reduce the risk of overdosing. These ABSDs are mathematical transformations of height and weight that represent fat-free weight and follow the same principles as body surface area (BSA)-based dosing of cancer chemotherapy. However, ABSDs are rarely studied in pivotal phase III studies and so can risk the underdosing of antimicrobials in patients with obesity when incorrectly applied in the real-world setting. Specific case examples are presented to highlight these risks. Although general principles may be considered by clinicians, a universal approach to dose modification in obesity is unlikely. Studies that can better distinguish human body phenotypes may help reduce our reliance on height and weight to define dosing. Simple and complex technologies exist to quantify individual body composition that could improve upon our current approach. Early evidence suggests that body composition parameters repurposed from medical imaging data may improve upon height and weight as covariates of drug clearance and distribution. Clinical trials that can integrate human body phenotyping may help us identify new approaches to optimal dose selection of antimicrobials in patients with obesity.