CHILDHOOD OBESITY AND THE ANAESTHETIST

Continuing Education in Anaesthesia, Critical Care & Pain , August 13, 2012

Abstract and Introduction

Introduction The World Health Organization has stated that:

Worldwide obesity has more than doubled since 1980. In 2008, 1.5 billion adults were overweight. Of these over 200 million men and nearly 300 million women were classified as obese. Nearly 43 million children under the age of five were overweight in 2010. 65% of the world's population live in countries where being overweight kills more people than being underweight. In the UK 66% of the adult population are overweight or obese. Obesity is preventable.[1]

This presents what may be an insurmountable problem for healthcare providers, despite wellpublicized campaigns to highlight the dangers of obesity to the individual. Adult obesity is a well-recognized problem with comorbidities and anaesthetic problems being well documented. Many anaesthetists classify obese adult patients as ASA II, regardless of the presence of any overt comorbidity. There is less information on obesity in children and until recently, it was uncertain that obese children were prone to the same comorbidities and anaesthetic risks as adults. However, research from the USA and elsewhere indicates that comorbidities are becoming more common and that they are at increased risk of adverse events associated with anaesthesia and surgical procedures.
[2,3]

We have realized that greater numbers of overweight and obese children are presenting for surgery at our tertiary hospital, often with no anticipation of their greater care needs or any additional investigations or concern for the difficulties they pose for the anaesthetist. Indeed, the fundamental measure of BMI is not routinely recorded. In this article, we explore the challenges for anaesthetizing this group of children.

Challenge 1
Defining Childhood Obesity

BMI, weight (kg)/height2 (m2), is a measure of ideal weight range and used by organizations such as the World Health Organization (WHO) as a guide to obesity in adults (Table 1). Unfortunately, children are less straightforward when it comes to defining obesity and the label of overweight or obese child has been rather more arbitrarily assigned. This is because BMI is more difficult to define in childhood as the child is continuing to grow. Growth in childhood has traditionally been measured using the widely validated growth charts for boys and girls up to the age of 18 with height and weight indices expressed in centiles (Fig. 1). Healthcare professionals are familiar with these centile charts, but BMI also changes with age as children develop, in such a way that, for example, a BMI of 20 at the age of 8 yr is equivalent to a BMI of 30 at the age of 18 yr. To overcome these difficulties, gender-specific BMI charts were produced by Cole and colleagues[4] in 2000 and the centiles for 'overweight' and 'obese' were defined by projecting back from where they crossed the BMI of 25 and 30 curves, respectively, at the age of 18 yr. Similar charts have now been produced by the WHO (Fig. 2a and b).

Chart+ BMI

The World Health Organization and the International Obesity Task Force have both recognized that obesity is fast becoming a global epidemic and therefore the measures outlined above to better define childhood obesity will facilitate more accurate detection of affected individuals at an early age. This is particularly important as the literature suggests that obese children grow into obese adults with all the attendant comorbidities. With this clearer definition of obesity, the anaesthetist will be able to recognize the overweight or obese child and so enable them to optimize their perioperative care.

Challenge 2
Preoperative Care Children presenting for surgery are a heterogeneous group. Both the NHS plan and the European Charter of Children's Rights place great emphasis on the majority of paediatric surgery being performed as a day case as much as realistically possible.[5,6] Most children presenting for minor surgery who are free of significant chronic illness can be managed safely as a day case, but obesity could confound this aspiration for some patients. Until recently, it was thought that obese children had essentially a normal physiology and that the adult comorbidities associated with obesity did not affect them. However, recent literature would appear to contradict this. A paper from the USA showed that obese children were just as

likely to suffer with hypertension, type II diabetes, asthma, gastro-oesophageal reflux, and obstructive sleep apnoea as their adult counterparts[7] (Table 2). The challenge for this group of patients is to effectively screen for the major comorbidities before operation. Identification of this group of children needs to be pro-active. Children's BMI measurement ideally needs to be performed a month before their surgery and children who demonstrate obesity need to have further screening investigations. Investigations alongside routine pulse and temperature measurement may need to include: arterial pressure, ECG, blood glucose, and cholesterol measurement. Screening for obstructive sleep apnoea may indicate the need for overnight oximetry, formal sleep studies, and other respiratory function tests, including arterial blood gas analyses. Additionally, assessment for gastro-oesophageal reflux with the commencement of suitable medication before surgery should be considered. It will not be possible to refer every obese child to a tertiary centre in the UK: the majority will be cared for in district hospitals, despite there being an increased risk of anaesthetic problems. The way forward will be to identify those with specific risks, to identify those where an overnight stay or high-dependency care is needed, and, to some extent, by adapting anaesthetic techniques.

Challenge 3
Perioperative Management Obese teenagers especially can cause problems because of their absolute weight and size. Trolley and operating table limits need to be observed, and lifting and moving equipment needs to be available. Suitably sized chairs, wheelchairs, and beds need to be available for them. This is actually likely to be less of a problem in hospitals that also provide adult services. Radiological investigations may also prove a challenge: there is a width limit on CT and MRI scanners that could be relevant (our own CT scanner has a width limit of 70 cm). Induction For most obese children, i.v. induction is preferred and a rapid-sequence induction technique may need to be considered due to increased risk of acid aspiration. However, venous access may be more difficult in this group secondary to increased s.c. fat deposits. Most children find prolonged and repeated cannulation attempts difficult and distressing, even with distraction techniques and topical anaesthesia, and may only co-operate for a short period, so the inhalation route may need to be considered. Gas induction may lead to an increased risk of airway complications. It is more difficult to maintain a patent airway, and obese children desaturate even more quickly than their non-obese peers. The use of sedative premedication before induction in the nervous obese child will require careful consideration because of increased risk of postoperative respiratory obstruction.

Airway Maintenance It is safer to use a tracheal tube rather than laryngeal mask airway (LMA) in this group even for minor surgery. Correct sizing for the LMA is often difficult in the obese child, leading to inadequate seal, air in the stomach, and therefore increased aspiration risk. Decreased lung compliance in the obese child may result in hypoventilation, when an LMA is used. Intubation has not generally been shown to be a problem in obese children;[2,7] however, inability to obtain correct head positioning before intubation may lead to a poorer view at laryngoscopy. The child may need to be positioned using several pillows and slightly head-up to minimize diaphragmatic splinting. Preoxygenation to delay desaturation in the event of difficult intubation is recommended, although children find face masks confining and may not comply with this. Airway adjuncts to deal with difficult intubation need to be available. Obese children will more frequently require positive pressure ventilation with the addition of PEEP to prevent basal collapse and may also require higher ventilatory pressures due to reduced lung compliance. The risk of barotrauma will therefore be higher in this group of children. Most of the published research agrees that obese children all have a much higher risk of bronchospasm, laryngospasm, and oxygen desaturation perioperatively than their non-obese peers, making this a high-risk group of children presenting for surgery Haemodynamic Monitoring Monitoring of the obese child under anaesthesia presents a challenge. ECG monitoring is not usually problematic, although increased impedance due to a higher proportion of body fat may lead to a poor signal. However, accurate arterial pressure and oxygen saturation monitoring may be adversely affected by increased body mass. It may be difficult to achieve correct arterial pressure cuff sizing in the obese paediatric patients as larger cuff sizes such as those used for obese adults may not be readily available. Also the correct cuff size may simply be too big for the length of the child's arm or leg. This may lead to over/under reading of arterial pressure. Invasive arterial monitoring may be a solution to this problem; however, there is the practical difficulty in obtaining arterial access in this population, and invasive arterial monitoring is not without its own problems such as arterial occlusion, leading to possible limb ischaemia. Oxygen saturation monitoring problems can often be overcome with the use of an ear probe or in smaller children use of a wrap-around type saturation probe. Positioning Positioning of obese children presents a challenge, as with obese adults, it is important to prevent pressure necrosis during prolonged procedures. For younger obese patients, additional padding and attention to bony prominences as with all patients may be sufficient. The morbidly obese teenager however may present a greater problem, especially in the tertiary paediatric centre used to a much smaller population. Staff may require additional training in moving and handling techniques to avoid injury to themselves and the patient. Special operating tables that are able to take greater weights may be required. Positioning during laparoscopic surgery in this group may

require special thought as steep head up or down will put the patient at risk without the addition of restraints. Adverse effects associated with prone positioning are well documented in the adult population.[8] For the obese child, prone positioning presents a greater challenge. Adequate ventilation may be impossible to achieve due to diaphragmatic splinting secondary to increased abdominal girth and pressure effects. Special operating tables again may be required, haemodynamic stability may be difficult to achieve, and pressure necrosis may be a real issue for this group. Fluid Management Complex operative procedures may lead to the loss of significant fluid volumes, both evaporative and blood loss. Fluid monitoring and replacement presents a challenge in this group. The surgical procedure itself may be more technically difficult due to body morphology which may lead to increased fluid depletion and there is the dilemma of whether fluid replacement should be based on actual body weight or lean body mass. For major procedures, the assessment of fluid status may require formal invasive haemodynamic monitoring or the use of devices, such as LiDCO or oesophageal Doppler probe monitoring, and formal haemoglobin assessment as a guide for blood replacement. Drug Administration The dosage of medicines in children is usually calculated on a milligram per kilogram basis. Drug dosing in obese children presents a particular challenge. Dose calculation using total body weight for many of the anaesthetic agents may lead to overdose and subsequent adverse physiological sequelae. Therefore, the calculation of drug dosing on ideal body weight or even lean body mass may be preferred.[9,10] There are exceptions to this, for example, succinylcholine should be given using total body weight to optimize intubating conditions,[11] which may result in uncomfortably large doses of drug being given to the obese child. Other neuromuscular blocking agents should be given as an ideal body weight dose with careful reversal of neuromuscular block at the end of the procedure. Administration of i.v. paracetamol also presents some difficulty. Dosing on total body weight may result in overdose and subsequent liver toxicity; therefore, it is safer to dose using ideal body weight, although this may appear to be under administration of the agent. Pharmacokinetics are altered in the obese; this is reflected in the dosing calculations for most target-controlled infusion models that calculate lean body mass as part of their programming. However, in the very obese patients, even lean body mass may not be accurate and further dose adjustments may be required. BIS monitoring may be especially helpful as a guide to adequate depth of anaesthesia. When volatile agents are used to maintain anaesthesia, desflurane may be preferred because of its low solubility, permitting faster wake-up (most obvious after prolonged surgery). Remifentanil infusions are also commonly used to facilitate smooth extubation and rapid wakeup.

Postoperative Care Obese children have an increased incidence of airway obstruction after operation and also require a longer duration of stay in the post-anaesthesia care unit (PACU) after their procedure.[2] In the immediate postoperative period, oxygen therapy will be required and may need to be continued once the child is on the ward. Obese children should be extubated fully awake after the return of airway reflexes to minimize the risk of airway obstruction and positioned appropriately to prevent airway obstruction in PACU. Constant observation with oxygen saturation monitoring is vital. Adequate postoperative analgesia should be given and additional analgesia prescribed as necessary; however, large doses of sedating opioids may increase the risk of delayed airway obstruction and so should be carefully titrated to minimize risk on the ward or at home. The use of regional analgesia should be encouraged as much as possible to avoid this; however, this may not always be practical, especially if the child is a day case, and it technically may be more difficult to achieve the correct placement of a regional block in this group.[12] Control of nausea and vomiting is important for all children; the use of multi-modal antiemetics will need to be considered, although there is no substantial evidence that obese children are at increased risk of emetic symptoms. Patients with a history of obstructive sleep apnoea will require an overnight stay and may need monitoring in a high-dependency unit. This potentially has resource and staffing issues and may mean that the child has to travel to a tertiary paediatric centre for their care rather than their local hospital, if such facilities are not available closer to their home.

Challenge 4
Bariatric Surgery in Adolescents As surgical treatment for the morbidly obese adult has become more common in the UK, there have been increasing numbers of children presenting for bariatric surgery. There are ethical concerns about using surgery to treat obesity in children, and NHS funding is not always granted. The patients who are operated on tend to be at the extreme end of the obesity spectrum and may have higher BMIs and actually be heavier than the average adult patients presenting for the same procedure. There is a balance of risks to consider in these very obese children, in that a higher risk surgical procedure, such as a gastric bypass, may be preferred over a low-risk one, such as a gastric band, on the grounds of long-term efficacy. The National Institute for Clinical Evidence (NICE) guidelines for the treatment of obesity in adults and children in the UK have been in place since 2006.[13] They state that bariatric surgery should be offered to children in only exceptional circumstances and only then if they fulfil certain criteria: i. achieved or nearly achieved physiological maturity;

ii.

have a BMI of 40 kg m2 or more, or between 35 and 40 kg m2 and other significant disease (e.g. type II diabetes, high arterial pressure) that could be improved if they lost weight; all appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months; they are receiving or will receive intensive specialist management; they are generally fit for anaesthesia and surgery; commit to the need for long-term follow-up.

iii. iv. v. vi.

Despite these strict criteria, increasing numbers of children are being offered bariatric surgery in tertiary paediatric centres. This group of adolescents may have significant psychological issues related both to their body morphology and also how they have been perceived by their peers because of their size, and therefore may need quite detailed counselling about their expectations of their surgery and also how they will psychologically cope in the future with the necessary dietary restrictions imposed by the surgical procedure. The anaesthetic issues relating to caring for an adolescent undergoing bariatric surgery are mainly the same as those involved in anaesthetizing an obese child. However, additional considerations particular to bariatric surgery will include particular attention to patient positioning, postoperative pain relief, thromboprophylaxis, and where to care for the adolescent after operation. Positioning A previous paper by Sabharwal and Christelis[14] in this journal concerning bariatric surgery in adults gives practical advice concerning patient positioning. Important considerations include ensuring that the patient does not slip off the table by utilizing foot rests and appropriate restraints. Arm rests are generally used, and it is important that pressure areas are well padded to prevent pressure sores. The patient may be in a steep head-up or head-down position. Creation of a pneumoperitoneum and liver retraction to obtain access to the stomach may all lead to decreased lung compliance with subsequent difficulties with ventilation. Good communication between surgical and anaesthetic teams is vital to maintain patient safety during the procedure. Postoperative Analgesia Pain relief should be provided using multi-modal analgesia. Most adolescents tolerate laparoscopic surgery well. Wound infiltration with appropriate volumes of local anaesthesia followed by regular paracetamol and non-steroidal anti-inflammatory drugs (if not contraindicated) and weak opioids such as codeine phosphate or tramadol may all be used. The use of

patient-controlled analgesia (PCA) containing morphine or fentanyl may be considered but will carry the additional side-effect risk of nausea, sedation, or both, which may delay early mobilization and recovery. If the surgery needs to be converted to an open procedure for any reason, then epidural analgesia or regional block such as a transverses abdominus plane and rectus sheath block (with PCA) will need to be considered, although body mass may make this technically difficult. Thromboprophylaxis Venous thromboembolism (VTE) is uncommon in the paediatric population; however, obese patients are at risk of developing a VTE after operation. To reduce this risk, early postoperative mobilization is recommended, use of mechanical methods such as calf compression during surgery with compression stockings applied before surgery, with larger sizes being available. The value of low-molecular-weight heparin is less clear in the under-16 yr age group, with obesity being a risk factor but not enough on its own to indicate its use. Postoperative Care of the Bariatric Patient It is important that the adolescent is cared for in a safe environment after operation as they are at risk of developing respiratory problems and surgical complications. They should be nursed on the appropriate bed with electrical controls to aid positioning and in an environment with the ability for appropriate monitoring facilities for at least 24 h post-surgery. This may be in a highdependency unit, depending upon the surgery performed, or at least an area with continuous oxygen saturation monitoring, and adequate numbers of the nursing team to assist in positioning (usually to be upright as much as possible). Supplemental oxygen will usually be required in the immediate postoperative period and may be delivered by a mask or nasal cannulae. Facial continuous positive airway pressure may sometimes be required and should be considered early to prevent the development of respiratory compromise.

Conclusion
Managing the obese child is becoming a common scenario for the anaesthetist as the problem of obesity reaches epidemic proportions. However, these children are at an increased risk of problems occurring at any stage of the anaesthetic process, some of which may be potentially life threatening. As such, they have the potential to present a challenge to anaesthetic practice both now and in the future. References 1. Available from www.who.int/mediacentre/factsheets/fs311/en/(accessed 2 May 2011) 2. Nafiu OO, Reynolds PI, Bamgbade OA, Tremper KK, Welch J, Kasa-Vubu JZ. Childhood body mass index and perioperative complications. Paediatr Anaesth 2007;17:42630.

3. El-Metainy S, Ghoneim T, Aridae E, Abdel Wahab M. Incidence of perioperative adverse events in obese children undergoing elective general surgery. Br J Anaesth 2011;106:35963. 4. Cole TJ, Bellizi M, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. Br Med J 2000;320:12405. 5. The NHS Plan. A Plan for Investment. A Plan for Reform. London: HMSO; 2000. p. 22. 6. Alderson P. European Charter of Children's Rights. Bull Med Ethics 1993;92:135. 7. Tait AR, Voepel-Lewis T, Burke C, Kostrzewa A, Lewis I. Incidence and risk factors for perioperative adverse respiratory events in children who are obese. Anesthesiology 2008;18:37580. 8. Edgecombe H, Carter K, Yarrow S. Anaesthesia in the prone position. Br J Anaesth 2008;100:16583. 9. Baerdemaeker L, Mortier E, Strys M. Pharmacokinetics in obese patients. Contin Educ Anaesth Crit Care Pain 2004;4:1525. 10. Mortensen A, Lenz K, Abildstrom H, Loritsen T. Anaesthetising the obese child. Paediatr Anaesth 2011;21:6239. 11. Lemmens HJM, Brodsky JB. The dose of succinylcholine in morbid obesity. Anaesth Analg 2006;120:43842. 12. Smith HL, Meldrum DJ, Brennan LJ. Childhood obesity a challenge for the anaesthetist. Paediatr Anaesth 2002;12:75061. 13. Available from www.nice.org.uk/guidance/cg43 (accessed 2 May 2011) 14. Sabharwal A, Christelis N. Anaesthesia for bariatric surgery. Contin Educ Anaesth Crit Care Pain 2010;10:99103
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