Common Perioperative Complications in the Pediatric Day Surgery Setting of a Patient with an Elevated BMI: A Resource Guide to the Literature on the Care of the Obese Pediatric Surgical Patient

Abstract

The incidence of pediatric obesity is on the rise. Because pediatric overweight and obese patients are presenting for elective surgery in the day surgery setting, there are concerns regarding perioperative complications in this population. Although there is a paucity of studies specific to the pediatric population, respiratory symptoms, airway management concerns, prolonged postanesthesia care unit (PACU) stays, and increased emesis are significantly more common in pediatric patients with an elevated body mass index (BMI).¹ This resource guide will provide assistance to nurses and other healthcare providers to increase their awareness of the perioperative complications of pediatric patients with an elevated BMI in the day surgery setting.

Introduction

It is well known that an adult patient with an elevated body mass index (BMI) is at higher risk for certain perioperative complications.² Retrospective and prospective studies have also revealed that perioperative complications are more common in the pediatric perioperative setting if the patient has an elevated BMI. Childhood obesity has increased substantially in industrialized nations. The numbers vary by nation, but incidence has been recorded as high as 43%. In the United States, comparing the 20 years between the early 1960s and the late 1970s, the incidence of obesity in 6-to-11-year-olds increased by 54%. Morbid obesity increased by 98% during the same timeframe.¹ This trend becomes even more disturbing in light of the fact that 50% of obese children and 75% of obese adolescents become obese adults.³ Approximately one third of patients presenting to pediatric day surgery units are overweight or obese.²

Perioperative providers anticipate obese adult patients to present with comorbidities and screen them accordingly. These common comorbidities are also present in the pediatric population. There is a higher incidence of bronchial asthma, obstructive sleep apnea, reduced respiratory function including a reduction in the functional residual capacity (FRC), increased work of breathing and anatomical airway changes. In regards to the cardiovascular system, hypertension will likely be present. The obese patient will have a tendency toward noninsulin-dependent diabetes, fatty liver infiltration, and gastro-esophageal reflux disease.¹ However, it has not been demonstrated that these patients have higher gastric fluid volumes or decreased gastric emptying.^1,2

The obese pediatric patient is more likely to have perioperative complications if these comorbid conditions are present. The healthcare provider may experience difficulty with mask induction and intubation in the operating room^1,3 and laryngoscopy may prove problematic due to the anatomical differences.³ Studies, however, have not demonstrated a higher risk of bronchospasm or pulmonary aspiration. The risk of aspiration increases if the patient has obstructive sleep apnea.² The decision to administer a premedication, as well as how to calculate medications properly, has to be balanced between the likelihood of respiratory depression and the need for anxiolysis. Most drug doses are calculated based on lean body mass, which may be difficult to determine in this population. Obtaining preoperative intravenous access may be a problem.⁴ Medications should not be administered IM because the medication may only reach adipose tissue and not muscle.⁵ Monitoring may present a problem especially with proper sizing of the blood pressure cuff. Intravenous catheter insertion is hampered by the presence of adipose tissue. Positioning of the patient during the postanesthesia care unit (PACU) stay should be carefully considered, especially if the patient has a history of sleep apnea. The recumbent position may be helpful, as it allows the abdomen to shift away from the airway.¹ It has also been noted that these patients have an increased need for anti-emetic agents. Their PACU stay is often prolonged compared to the leaner pediatric patient.³ For the reasons outlined above, overweight and obese pediatric patient can present a challenge in the day surgery setting. An astute and attentive healthcare professional should be aware of the potential for complications and should be prepared to address the unique concerns of this population. In order to assist the healthcare provider care for this patient population, a selection of research studies and papers that address these issues has been compiled.

Materials and Methods

PubMed and CINHAL were used to locate quantitative or qualitative research about perioperative preparation of obese children. Results were limited to English language and the scope of the search was from 1980 to 2011. The following search terms were used: anesthesia, Body Mass Index (BMI), complications, obese, overweight, pediatric, surgery, pediatric surgery, perioperative. This bibliographic review should not be considered an exhaustive list of knowledge on the common perioperative complications of a pediatric patient with an elevated BMI.

Bibliographic Findings

The bibliographic findings in this article were selected due to the contribution they provide regarding common perioperative complications in the pediatric population with elevated BMI. Citations are categorized under the headings “comprehensive knowledge” and “perioperative care.”

Comprehensive knowledge

Choi, J.H., Kim, E.J., Choi, J., et al. (2010). Obstructive sleep apnea syndrome: a child is not just a small adult. Annals of Otology, Rhinology and Laryngology, 119, 656–661.

Cole, T.J., Bellizzi, M.C., Flegal, K.M., et al. (2010). Establishing a standard definition for child overweight and obesity worldwide: international survey. British Medical Journal, 320, 1240–1243.

Collins, C.E., and Everett, L.L. (2010). Challenges in pediatric ambulatory anesthesia: kids are different. Anaesthesiology Clinics, 28, 315–328.

DeBoer, M. (2010) Underdiagnosis of metabolic syndrome in non-Hispanic black adolescents: a call for ethnic-specific criteria. Current Cardiology Risk Reports, 4, 302–310.

Eberhart, L.H., Geldner, G., Kranke, P., et al. (2004).The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Anesthesia and Analgesia, 99, 1630–1637.

Fung, E., Cave, D., Witmans, M., Gan, K., and El-Hakim, H. (2010). Postoperative respiratory complications and recovery in obese children following adenotonsillectomy for sleep-disordered breathing: a case control study. Otolaryngology-Head and Neck Surgery, 142, 898–905.

Guo, S., and DiPietro, L.A. (2010). Factors affecting wound healing. Journal of Dental Residency, 89, 219–229.

Hackel, A., Badgwell, J.M., Binding, R.R., et al. (1999). Guidelines for the pediatric perioperative anesthesia environment, American Academy of Pediatrics, Section on Anesthesiology. Pediatrics, 103, 512–515.

Lawrence, J. (2005). Childhood obesity. British Journal of Perioperative Nursing, 15, 84–90.

Levin, P.D. (2009). Obesity, metabolic syndrome, and the surgical patient. The Medical Clinics of North America, 93, 1049–1063.

Smith, H.L., Meldrum, D.J., and Brennan, L.J. (2002). Childhood obesity: a challenge for the anaesthetist? Pediatric Anesthesia, 12, 750–761.

Tait, A.R., Voepel-Lewis, T., Burke, C., et al. (2008). Incidence and risk factors for perioperative adverse respiratory events in children who are obese. Anesthesiology, 108(3), 375–380.

Vu, L., Nobuhara, K., Lee, H., and Farmer, D.L. (2008). Determination of risk factors for deep venous thrombosis in hospitalized children. Journal of Pediatric Surgery, 43, 1095–1099.

Perioperative care

Atkins, M., White, J., and Ahmed, K. (2002). Day surgery and body mass index: results of a national survey. Anaesthesia, 57, 169–182.

Bandla, P., Brooks, L.J., Trimarchi, T., and Helfaer, M. (2005). Obstructive sleep apnea syndrome in children. Anesthesiology Clinics of North America, 23, 535–549.

Benumof, J.L. (2001). Obstructive sleep apnea in the adult obese patient: implications for airway management. Journal of Clinical Anesthesia, 13, 144–156.

Benumof, J. (2002). Obstructive sleep apnea in the adult obese patient: implications for airway management. Anesthesiology Clinics of North America, 20, 789–811.

Bond, A. (1993). Obesity and difficult intubation. Anaesthesia Intensive Care, 21, 828–830.

Borland, L., Sereika, S., Woelfel, S., et al. (1998). Pulmonary aspiration in pediatric patients during general anesthesia: incidence and outcome. Journal of Clinical Anesthesia, 10, 95–102.

Brenn, B. (2005). Anesthesia for pediatric obesity. Anesthesiology Clinics of North America, 23, 745–764.

Bryson, G., Chung, F., Cox, R., et al. (2004). Patient selection in ambulatory anesthesia—an evidence-based review: part II. Canadian Journal of Anaesthesia, 51, 782–794.

Camargo, Jr., C., Field, A., and Colditz, G. (1999). Body mass index and asthma in children aged 9–14. American Journal of Respiratory Critical Care Medicine, 159, 150A.

Cook-Sather, S., Liacouras, C., Previte, J., Markakis, D., and Schreiner, M.S. (1997). Gastric fluid measurement by blind aspiration in paediatric patients: a gastroscopic evaluation. Canadian Journal of Anaesthesia, 44, 168–172.

Dindo, D., Muller, M., Weber, M., and Clavien, P. (2003). Obesity in general elective surgery. Lancet, 361, 2032–2035.

Dunn, D. (November 2005). Preventing perioperative complications in special populations. Nursing 2005, 35, 36–43.

Eichenberger, A., Proietti, S., Wicky, S., et al. (2002). Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem. Anesthesia and Analgesia, 95, 1788–1792.

El-Metainy, S.G. (2011). Incidence of perioperative adverse events in obese children undergoing elective general surgery. British Journal of Anaesthesia, 106, 359–363.

El-Orbany, M., and Woehlck, H. (2009). Difficult mask ventilation. Anesthesia and Analgesia, 109, 6, 1870–1880.

Geliebter, A. (2001). Stomach capacity in obese individuals. Obesity Research, 9, 727–728.

Han, R., Tremper, K., Kheterpal, S., and O'Reilly, M. (2004). Grading scale for mask ventilation (letter). Anesthesiology, 101, 267.

Inselma, L.S., Milanese, A., and Deurloo, A. (2003). Effect of obesity on pulmonary function in children. Pediatric Pulmonology, 16, 130–137.

Jackson, S. (2007). More overweight/obese children having outpatient surgery—are you prepared? Same-Day Surgery, 31, 53–56.

Jurvin, P., Fevre, G., Merouche, M., Vallot, T., and Desmonts, J.M. (2001). Gastric residue is not more copious in obese patients. Anesthesia and Analgesia, 93, 1621–1622.

Kabon, B., Nagele, A., Reddy, D., et al. (2004). Obesity decreases perioperative tissue oxygenation. Anesthesiology, 100, 274–280.

Maltby, J.R., Pytka, S., Watson, N.C., McTaggart Cowan, R.A., and Fick, G.H. (2004). Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients. Canadian Journal of Anaesthesia, 51, 111–115.

Mortensen, A.L. (2001). Anesthetizing the obese child. Pediatric Anesthesia, 21, 623–629.

Myles, P.S., Leslie, K., Chan, M.T., Forbes, A., Paech, M.J., Peyton, P., Silbert, B.S., and Pascoe, E. (2007). The ENIGMA trial group: avoidance of nitrous oxide for patients undergoing major surgery. Anesthesiology, 107, 221–231.

Nafiu, O.O., Ndao-Brumlay, K.S., Bamgbade, O.A., Morris, M., and Kasa-Vubu, J.Z. (2007). Prevalence of overweight and obesity in a US pediatric surgical population. Journal of National Medical Association, 99, 46–51.

Nafiu, O.O., Ndao-Brumlay, K.S., Bamgbade, O.A., Morris, M., Kasa-Vubu, J.Z. (2002). Prevalence and trends in overweight among US children and adolescents, 1999–2000. Journal of the American Medical Association, 288, 1728–1732.

Nishina, K., Mikawa, K., Maekawa, N., Tamada, M., and Obara, H. (1994). Omeprazole reduces preoperative gastric fluid acidity and volume in children. Canadian Journal of Anaesthesia, 41, 925–929.

Noble, K. (2008).The obesity epidemic: the impact of obesity on the perianesthesia patient. Journal of Perianesthesia Nursing, 23, 418–425.

Ogden, C.L., Carroll, M.D., Curtin-Chung. F., Mezei, G., and Tong, D. (1999). Pre-existing medical conditions as predictors of adverse events in day-case surgery. British Journal of Anaesthesia, 83, 262–270.

Schnur, M.M. (May 2010). Optimal outcomes for the obese pediatric patient. OR Nurse Journal 2010, 26–33.

Setzer, N., and Saade, E. (2007). Childhood obesity and anesthetic morbidity. Pediatric Anaesthesia, 17, 321–326.

Tait, A.R., Voepel-Lewis, T., Burke, C., Kostrzewa, A., and Lewis, I. (2008). Incidence and risk factors for perioperative adverse respiratory events in children who are obese. Anesthesiology, 108, 375–380.

Veyckemans, F. (2008). Child obesity and anaesthetic morbidity. Current Opinion in Anaesthesiology, 21(3), 308–312.

Von Ungern-Sternberg, B.R. (2004). Effect of obesity and site of surgery on perioperative lung volumnes. The Board of Management and Trustees of the British Journal of Anaesthesia, 92, 202–207.

Wang, Y., and Lobstein T. (2006). Worldwide trends in childhood overweight and obesity. International Journal of Pediatric Obesity, 1, 11–25.

Warner, M.A., Warner, M.E., Warner, D.O., Warner, L.O., and Warner, E.J. (1999). Perioperative pulmonary aspiration in infants and children. Anesthesiology, 90, 66–71.

Wong, C.A., McCarthy, R.J., Fitzgerald, P.C., Raikoff, K., and Avram, M.J. (2007). Gastric emptying of water in obese pregnant women at term. Anesthesia and Analgesia, 105, 751–755.

Conclusion

A pediatric patient with an elevated BMI presents a unique challenge in the day surgery setting. A 2008 study of 2,025 children undergoing general pediatric surgery revealed that approximately 15% of the patients were obese.⁴ The available evidence suggests that this population is at risk for respiratory and postoperative wound complications. Since a significant body of knowledge is currently not available about the perioperative complications of a pediatric patient with elevated BMI, future research will assist nurses and interdisciplinary teams with providing appropriate care specific for this at-risk population. We hope this paper will help with providing guidance for providers with what is currently known.

Footnotes

Acknowledgments

The authors are indebted to the ongoing support received from the medical librarian Emily Lawson at Children's Healthcare of Atlanta at Egleston.

Author Disclosure Statement

No competing financial interests exist.

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