Childhood obesity: a growing problem for the pediatric anesthesiologist seminars in medicine perioperative pain and medicine 2006

1
Childhood obesity a growing problem for the
pediatric anesthesiologistseminars in
medicineperioperative pain and medicine2006

• R3 ???

2
Epidemiology

• ?? ? ?? ??????? prevalence of morbid obesity in
  children? ?? 30? ?? ?? ??.
• 1520? ???, ???? obese??? ??
• - 2004 JAMA article by Hedley et al
• 95percentile??? BMI? ?? ???
• 12-19? ????? 16.1
• 6-11?? 15.8
• 2-5?? 10.3?? ??.
• - ?? ??? ??? ???? obese children? ??
  medical risk factors? ?? obese adults? ??

3

• Childhood obesity ??? ????? BMI index??
  weight(kg)/height(m2)
• ??? ?? cutoff
• overweight - BMIgt 25kg/m2
• obesity - BMIgt 30kg/m2
• ??? ?? 2-20??? percentiles? ??? age and
  gender specific curve? ??
• ??, 2000? Centers for disease control?
  National center for health statistics?? update?
  ????
• overweight children BMI gt 85
  percentile
• obesity children BMI gt 95 percentile

4
Pathogenesis and pathophysiology

• Obesity is
• a complex, multi-factorial disease
• ???? ??? ??? obesity? hormonal
  aberration(hypothyroidism, cushing disease or
  genetic defect)?? ???? ?????, ??? ???? ??
  increased caloric intake, decreased energy
  expenditure? ???
• ??? ??? ??? positive caloric balance? weight
  gain?? ???? ??, children? ?? growth? ???
  energy???? ???? ???? restriction???

5
Co-morbidities of childhood obesity

• ?? childhood obesity?
• medical complication? ??? ? ??? ????? ???? ???
  ????? ??? ??, ????? ?? ???? ??? ??.
• Psychology- ????? ?? ??? ???, ??? ?????? ???,
  depression, low self esteem? ???? ??.

6

• Respiratory
• - obese adult? ????? FVC, FRC? ??? ??, obesity?
  ??? ?? static lung volume? ??? impaired diffusion
  capacity??
• - reactive airway disease? ??, obstructive
  sleep apnea? ?? obese children? 17?? ?? ??
• - increased respiratory infection
• - Pickwickian syndrome hypoventilation?? ??
  chronic hypoxemia, CO2 retention -gt
  hypersomnolence, polycythemia, pulmonary
  hypertension, hypoxemia, hypercapnia

7

• Cardiovascular
• increased adipose tissue-gt circulating blood
  volume? ??-gt cardiac output?????-gt stroke
  volume????-gt Lt. ventricular hypertrophy??- HTN
  ????? ?? ???
• Endocrine insulin resistance??-gt NIDDM??,
  abnormal lipid profile
• Hepatic and GI ??? ????? GERD, delayed gastric
  emptying??, fatty liver, steatohepatitis

8
pharmacology

• ???? ?? drug dosage? total body weight?? ideal
  body weight? ???? ???? ??
• - Children 1-18 yrs
• IBW(kg) Height2(cm) x 1.65/1000

9

• obese children? ?? body composition? ? ??? drug
  distribution? ?? ??
• -gt barbiturate, benzodiazepines?? highly
  lipophilic substances? volume of distribution? ?
  ??? ???, ???? ?????? less lipophilic substance?
  ??? ???. Hepatic metabolism? ?? ??? ??.
• ? ??? ?? ??? pharmacokinetic profile? ?? ????
  ??? ?? ?????? ?? ????, heart rate, blood pr.,
  level of sedation? ?? ?? ?????? ??

10
Volatile anesthetics

• Volatile anesthetics? ??? ??? ?? adipose tissue?
  ??
• - delayed recovery ??
• ? morbidly obese child? adult?? ?? ??- study?
  ??? obese patient? ???? desflurane, sevoflurane?
  ?? ?? recovery? ??
• Obese adult? ?? halogenated volatile anesthetics?
  biotransformation??? serum fluoride level? ?????
  nephrotoxicity? ?? ??? ??? ?? ?? obese pediatric
  patients??? ??? ??? unclear.

11
Local anesthetics in neuroaxial blocks

• Obese patients shifting blood from inf. Vena
  cava ? fatty infiltration?? ??epidural space? ??
  local anesthetic dosage? ????( 20-25)

12
Bariatric surgery

• adult??? ???? weight loss surgery?
  adolescents??? ???? ??? ???? optimal timing? ??
  ??? ??.

13
Anesthetic management
14
Preoperative considerations

• GERD greater risk population for reflux and
  aspiration pre op. H2 blocker(as ranitidine)?
  ?? ? ? ??.
• metoclopramide given both 12 hours and 2
  hours prior to surgery ??? children??? ???
  ?????.- ?? strict N.P.O guideline? ??

15

• Airway assessment- obese child?? pre op.
  visiting? ?? airway evaluation? ??! mouth
  opening, dentition, Mallampati scores,
  thyromental distance, neck range of motion-
  induction? soft tissue? oral cavity?? collapse?
  ?? submental space? ??? ??, shoulder fat
  deposition?? neck extension? ??
• fiberoptic intubation? ?? ??? ??.

16

• Pulmonary assessment- ??? PFT? check ?? pediatric
  pulmonologist? ??? ??
• post op. CPAP or bi level positive airway
  pressure? ?? ? ? ??.
• ?? ? ??? pulmonary assessment? ?? ?? ? post op
  respiratory support ?? ??? ?? ???? ???? ??.
• Cardiac assessement- HTN? ?? ??, EKG? cardiac
  ultrasound? ?? ventricular dysfunction????

17

• Post-operative pain management
• - ??? opioid ????( respiratory depression),
  regional technique? ??
• Technical issues
• IV access? ??? ? ??? ?? ? ???? ?? ? central
  venous access??, BP cuff size??

18
Intra-operative considerations

• Monitoring
• - obesity? ???? upper arm? ?? conical shape? ??
  ????? ?????? ??? ? ??, tidal CO2? PaCO2??? ? ?
  ???? arterial line cannulation? ??.
• Positioning
• - high incidence of peripheral nerve injury??.
• - head up positioning relieve pressure on the
  lungs from the abdominal viscera
• - anti embolic stocking

19

• Induction
• Overall aspiration risk? ??? ?? ?? Borland and
  colleagues? 5000 case? obese children? 1
  episode?? ??.
• cricoid cartilage pressure? ??? Rapid sequence?
  ??
• Problem ?? ? ??? ?????? induction? second trained
  anesthesia provider? ?? ?? ?? ?? ???.
• 3-4? ??? preoxygenation??
• decreased FRC, increased metabolic rate? ??
  rapid O2 desaturation during hypoventilation??
• slight reverse Trendelenburg positon with a
  small amount of PEEP? ??.

20

• Obese patient? greater risk for post operative
  nausea and vomiting?? ??
• Mechanical ventilation- V/Q mismatch? ??
• 10-12 ml/kg( based on IBW), low level of PEEP(
  ??? PEEP? cardiac performance? ?? ?? ? ??)
• Extubation- full reversal of neuromuscular
  blockade, suction the oropharynx and stomach,
  good respiratory mechanics and stable vital
  signs??
• semisitting position( abdominal pressure? ?? FRC?
  30?? ????)