More overweight/obese children having outpatient surgery — Are you prepared?
Outpatient surgery providers are seeing increasing numbers of children who are overweight and obese, and these children have a greater likelihood of experiencing problems associated with surgery, according to a recent study conducted by the University of Michigan Health System.1
The percentages of children who are overweight has almost doubled in the last 25 years, and the percentage of overweight adolescents has tripled.2 About 18% of school children in the United States are considered overweight.2
"These patients pose a risk to an outpatient center due to the increased frequency of complications and need for prolonged monitoring," says Ann K. White, MD, FACS, FAAP, pediatric otolaryngologist at Atlanta Children's ENT in Alpharetta, GA.
As outpatient surgery providers see more overweight/obese children and adolescents, they also have seen increased rates of diseases that often accompany higher body weights, such as Type II diabetes, hypertension, asthma, and other breathing problems. The increased prevalence of these diseases has boosted the need for vigilance in the outpatient setting to properly manage the diseases during surgery and avoid discharge delays.
Paul Samuels, MD, associate professor of anesthesiology and pediatrics at Cincinnati Children's Hospital, says that all children with underlying problems are at higher risk for requiring overnight hospitalization "if their diseases are not adequately controlled prior to discharge."
A preoperative screening for appropriate facility placement is absolutely imperative to the health of the child and success of the surgical procedure, White says. Often the procedure may go well, but the postoperative course is complicated by the child's underlying health conditions, she says. "These risks must be assessed and problems anticipated," White says. "In our litigious society, those at increased risk must be cared for in appropriate facilities to ensure a healthy outcome for all involved in the care of the patient."
Screening should included, at a minimum, a through history that covers snoring, difficulty breathing, exercise tolerance, frequency of respiratory illnesses or symptoms, sleep-related problems, past anesthetic difficulties, and reflux, White says. If the patient has a history of exercise intolerance, shortness of breath, or chest pain on exertion, an electrocardiogram and possibly an echocardiogram should be obtained, White says. Those with severe OSA probably ought to have some cardiac evaluation, says Olubukola O. Nafiu, MD, FRCA, a resident in the Department of Anesthesiology at the University of Michigan in Ann Arbor.
Additionally, White says, "If there has been a history consistent with metabolic difficulties, then fasting blood chemistry and possibly thyroid function tests may be useful. Also, a sleep study is not always indicated, but a good sleep history is essential, she says.
However, if the patient has symptoms highly suggestive of sleep apnea, then the "gold standard" is a sleep study, says Richard A. Beers, MD, professor of anesthesiology at State University of New York (SUNY) Upstate Medical University in Syracuse.
Areas to consider for inpatient vs. outpatient
The surgeon should take an extensive history, then decide on appropriate screening tests, White advises. The patient should be evaluated at least seven days before the date of surgery by the anesthesia clinic, she says. "This time frame allows for additional tests to be completed before scheduled surgery date, if needed," White says. "Pending this risk determination, the child may or may not be a candidate for an outpatient facility," she says.
In Beers' opinion, the anesthesia history and physical examination should include the child's obstructive sleep apnea symptoms, signs, and physical characteristics, as well as the patient's overall exercise tolerance and any history suggestive of diabetes mellitus.
Another consideration is the type of surgery. "Airway surgery or surgery on a body cavity would be much more likely to require admission than peripheral surgery on an extremity or superficial structure such as the skin or superficial lymph node," Beers says.
It is imperative that obese children be pre-screened prior to having surgery and anesthesia on an ambulatory basis, especially if the procedure is taking place in a freestanding center not physically connected to an overnight facility, Beers says. "If there is any doubt about whether or not the patient has a history or physical findings consistent with obstructive sleep apnea, then the patient should have arrangements made for admission to a monitored setting post-anesthesia."
At this point, there isn't enough published data to categorically say that obese children should be excluded from outpatient surgery, Nafiu says. However, "clinical experience and adult derived data would suggest that children with extremely high body mass indices [BMI], for example BMI greater than 35 at any age, deserve further screening and should probably not be scheduled for outpatient surgery, or at the very least, plans should be made for postoperative admission should this be necessary," Nafiu says. No morbidly obese child should every have surgery at a freestanding center, White contends.
For other obese children, there is no one test that will clearly distinguish who needs postoperative observation in a hospital, Beers says. However, examine these patients for a significant history of obstructive sleep apnea (OSA), Nafiu says. "OSA, which has a strong correlation with obesity even in children, will make me worry about day surgery in an obese child," he says.
Be prepared for these complications
In addition to the published study mentioned above, the University of Michigan in Ann Arbor also has studied complications of obese children following surgery, says Nafiu, who also is the lead author of the Michigan study.3 "We did find that obese children are more likely to have difficult mask ventilation, laryngoscopy, and are more likely to stay longer in the post-anesthesia care unit," Nafiu says.
Outpatient surgery providers need to be prepared for these specific potential problems:
• Preoperative problems.
Preoperative problems include the management of known comorbidities, or the identification of unknown ones, says Samuels. "For instance, the patient may come into the hospital without their obstructive sleep apnea formally diagnosed," he says.
Overweight and obese children may have difficulty with preoperative sedation due to a history of sleep apnea, and the sedation may precipitate obstructive apnea, Beers says.
Expect to see an increasing number of children with hypertension and diabetes, say sources interviewed by Same-Day Surgery. "Hypertension, if present, must be controlled prior to surgery, as does their blood sugar [need to be controlled]," White says. "Diabetic patients have to be scheduled first in the morning, or blood sugars can rise significantly."
• Perioperative problems.
Positioning of an obese patient for a surgical procedure is "always difficult" due to the presence of a short, fat neck and limited neck mobility, White says.
During surgery, appropriate drug dosing is a challenge, sources say. There is little pharmacologic information on how to appropriately dose anesthesia drugs in this patient population, Samuels says. "This could result in either over- or underdosing of drugs, resulting in oversedation, breakthrough pain, or an increased risk of infection," he says.
Airway management is another challenge, sources say. Patients may have decreased oxygen reserve, so it's important to preoxygenate as best as possible, Beers says.
Visualization of the larynx for intubation is often difficult because children have high anteriorly positioned larynges normally, White says.
Airway devices such as a nasopharyngeal airway can be helpful for airway problems, Beers says, as well as postoperative admission or observation for several hours.
Another issue: Opening and closing of the wound takes longer with overweight/obese children due to the thicker fat layers, White says.
• Postoperative problems.
Initially after surgery, the biggest challenge is making sure the patient is breathing adequately after extubation, White says. "Due to a heavier chest wall, the patient must exert more effort to breathe," she says. Atelectasis can be a problem leading to poor oxygenation and the need for supplemental oxygen, White says. "One must monitor for post-obstructive pulmonary edema after [tonsillectomy and adenoidectomy]," she says. "If there is a history of sleep apnea, these patients are at risk for apneic periods and desaturations."
Airway obstruction in the postoperative period can be dangerous, Samuels warns. "Some patients will also require postoperative respiratory management, such as the use of CPAP [continuous positive airway pressure] to keep their airway unobstructed," he says. "Appropriately monitoring these patients in the postoperative period is very important."
After surgery, overweight/obese children face more likelihood of hospital admission for monitoring of oxygenation and ventilation, as well as bleeding, Beers says.
Also following surgery, preoperative comorbidities still have to be managed, Samuels warns. "In addition, the use of pain medication can complicate some of these diseases," he says.
Overweight/obese children often require more drugs to treat post-op nausea and vomiting, Nafiu says. Samuels adds, "Once again, the appropriate dosing of pain medication can be problematic."
- Nafiu OO, Ndao-Brumblay KS, Bamgbade OA, et al. J National Med Assn 2007; 99:46-50.
- Associated Press. Bush urges parents to get kids outdoors. Feb. 1, 2007. Accessed at www.nytimes.com/aponline/us/AP-Bush-Childhood-Obesity.html.
- Nafiu OO, Reynolds PI, Bamgbade OA. Childhood body mass index and perioperative complications. Pediatric Anesthesia 2007. doi:10.1111/j.1460-9592.2006.02140.x.