Anesthetic and pharmacologic considerations in perioperative care of obese children

Chidambaran, Vidya; Tewari, Anurag; Mahmoud, Mohamed

doi:10.1016/j.jclinane.2017.12.016

Cited by 24 publications

(31 citation statements)

References 123 publications

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“…However, obese children generally do not receive such interventions as their excess weight is seen as a marker of nutritional homeostasis, though this may not be the case 39‐41 . Furthermore, obese children are at increased risk for perioperative events that prolong LOS, such as adverse respiratory events 42 …”

Section: Discussionmentioning

confidence: 99%

Determinants of length of stay after pediatric liver transplantation

Covarrubias

Luo

Massie

et al. 2020

Pediatric Transplantation

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Background:We sought to identify factors that are associated with LOS following pediatric (<18 years) liver transplantation in order to provide personalized counseling and discharge planning for recipients and their families. Methods:We identified 2726 infants (≤24 months) and 3210 children (>24 months) who underwent pediatric liver-only transplantation from 2002-2017 using the Scientific Registry of Transplant Recipients. We used multilevel multivariable negative binomial regression to analyze associations between LOS and recipient and donor characteristics and calculated the MLOSR to quantify heterogeneity in LOS across centers. Results:In infants, the median LOS (IQR) was 19 (13-32) days. Hospitalization prior to transplant (ICU ratio: 1.46 1.59 1.70 ; non-ICU ratio: 1.08 1.16 1.23 ), public insurance (ratio: 1.03 1.09 1.15 ), and a segmental graft (ratio: 1.08 1.15 1.22 ) were associated with a longer LOS; thus, we would expect a 1.59-fold longer LOS in an infant admitted to the ICU compared to a non-hospitalized infant with similar characteristics. In children, the median LOS (IQR) was 13 (9-21) days. Hospitalization prior to transplant (ICU ratio: 1.49 1.62 1.77 ; non-ICU ratio: 1.34 1.44 1.56 ), public insurance (ratio: 1.02 1.07 1.13 ), a segmental graft (ratio: 1.20 1.27 1.35 ), a living donor graft (ratio: 1.27 1.38 1.51 ), and obesity (ratio: 1.03 1.10 1.17 ) were associated with a longer LOS. The MLOSR was 1.25 in infants and 1.26 in children, meaning if an infant received a transplant at another center with a longer LOS, we would expect a 1.25-fold difference in LOS driven by center practices alone. Conclusions:While center-level practices account for substantial variation in LOS, consideration of donor and recipient factors can help clinicians provide more personalized counseling for families of pediatric liver transplant candidates. K E Y W O R D S length of stay, liver transplantation, MELD, pediatric, PELD Approximately 600 children with ESLD will undergo liver transplantation annually in the United States, with priority given to the sickest candidates as determined by the PELD/MELD score. 1 Understanding hospital LOS is necessary to provide more personalized counseling and discharge planning for pediatric liver transplant recipients and their families. 2 From a more practical perspective, understanding LOS is important for families when considering how duration of hospitalization will affect other aspects of their lives, such as arranging childcare for siblings, requesting time off work, and coordinating travel between the transplant center and the patient's home. 3 Most importantly, a prolonged hospitalization places pediatric liver transplant recipient at risk for developing hospital-acquired infections.Finally, from a financial perspective, a longer LOS incurs more costs; a longer LOS in adult liver transplant recipients has been tied to increasing costs and resource utilization. 4A previous multi-center study from the pre-PELD/MELD era of pediatric liver transplantation found that recipients...

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Section: Discussionmentioning

confidence: 99%

Determinants of length of stay after pediatric liver transplantation

Covarrubias

Luo

Massie

et al. 2020

Pediatric Transplantation

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“…Patients with obesity-related OSA are known to have higher rates of postoperative hypoventilation and oxygen desaturation due to hypersensitivity to opioids; therefore, opioid-sparing techniques are highly recommended for postoperative pain management in patients with obesity [ 170 , 171 , 172 ].…”

Section: Postoperative Respiratory Concernsmentioning

confidence: 99%

Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient

Egbuta

Mason

2020

JCM

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There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.

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“…Our findings indicate that existing published studies on therapeutics in pediatric obesity are sparse and have not focused on some of the most prevalent agents used in hospitalized pediatric patients. When no pediatric information exists in the literature to inform drug use, clinicians and researchers often rely on expert opinion and evidence from adult populations (7). For PK data derived from adult obesity studies, extrapolation to pediatric patients has limitations.…”

Section: General Critique and Points Of Special Interestmentioning

confidence: 99%

“…Obesity is a progressive disease associated with pathophysiological changes in multiple organ systems: respiratory, hepatic, renal, cardiometabolic (hypertension, atherosclerosis, dyslipidemia), and insulin resistance, even among children with metabolically healthy obesity (7,8). When obesity continues into adulthood, there are long‐term health complications (e.g., cardiovascular events), especially for individuals with severe obesity (9).…”

Section: Introductionmentioning

confidence: 99%

Dosing Common Medications in Hospitalized Pediatric Patients with Obesity: A Review

Ameer

Weintraub

2020

Obesity

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Medication management in children and adolescents with obesity is challenging because both developmental and pathophysiological changes may impact drug disposition and response. Evidence to date indicates an effect of obesity on drug disposition for certain drugs used in this population. This work identified published studies evaluating drug dosing, pharmacokinetics (PK), and effect in pediatric patients with obesity, focusing on 70 common medications used in a pediatric network of 42 US medical centers. A PubMed search revealed 33 studies providing PK and/or effectiveness data for 23% (16 of 70) of medications, 44% of which have just one study and can be considered exploratory. This work appraising 4 decades of literature shows several promising approaches: greater use of PK models applied to prospective clinical studies, dosing recommendations derived from both PK and safety, and multiyear effectiveness data on drugs for chronic conditions (e.g., asthma). Most studies make dose recommendations but are weakened by retrospective study design, small study populations, and no controls or historic controls. Dosing decisions continue to rely on extrapolating knowledge, including targeting systemic drug exposure typically achieved in adults. Optimal weight‐based dosing strategies vary by drug and warrant prospective, controlled studies incorporating PK and modeling and simulation to complement clinical assessment.

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Anesthetic and pharmacologic considerations in perioperative care of obese children

Cited by 24 publications

References 123 publications

Determinants of length of stay after pediatric liver transplantation

Determinants of length of stay after pediatric liver transplantation

Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient

Dosing Common Medications in Hospitalized Pediatric Patients with Obesity: A Review

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