Pediatric obesity...Really Difficult case

Obese pediatric patients do worse than their lean counterparts with respect to:

Critical care

(1)Obese children have longer ICU stays and.

(2)Obese children have more complications (sepsis and post-operative fistulas).

Surgical conditions (ex. Appendectomy)

(1)Diagnosis is more difficult – more likely to have CT scans versus U/S

(2)Increased risk for conversion of laproscopic to open procedure

(3)Have increased surgical times

(4)Have increased risk for wound infections

Pulmonary conditions

 

(1)Longer length of stay for obese children admitted to ICU for status asthmaticus.

(2)Increased risk for developing atelectasis

(3)Have decreased chest wall compliance

(4)Sleep-disordered breathing (OSA) is very common cause of morbidity affecting 37-46% of the obese pediatric population (45% of these patients still had symptoms even after tonsillectomy).

Cardiopulmonary arrest

(1)Obesity is independently associated with worse odds of event survival and surviving to hospital discharge after in-hospital CPR.(2)Quality of CPR

(a)Airway more easily occluded
(b)May have less effective chest compressions
(c)PALS medications are weight based and may be inappropriate for the patient.     
       (i)Water-soluble medications (Epinephrine) may be at elevated serum levels.     
      (ii)Lipophilic medications (Amiodarone) may be at decreased serum levels.

d)Resuscitation Considerations

Airway
(1)Being supine is a problem.  Hypertrophied soft tissues more readily obstruct the airway.
(2)Be prepared to use oral airways and naso-airways while bagging (Jaw Thrust alone might not be sufficient).
(3)Ensure you align the external auditory meatus with the sternal notch (just like in adults) when preparing for intubation.

Breathing
(1)Desaturate even faster than normal.     
    (a)Recall that pediatric, obese, and pregnant patients are the fastest to desaturate normally: now you have two of those issues in one patient.
     (b)Smaller airways lead to smaller functional residual capacity (FRC).
     (c)Abdominal and thoracic adiposity further reduce the FRC.
     (d)Increased metabolic rate (consuming ~ twice as much oxygen/minute as adults)
(2)Decreased chest wall compliance (due to thoracic adiposity) can impede ventilation
(3)Placing patient in Reverse Trendelenburg can help displace some of the constrictive force of the thoracic and abdominal adiposity (again, just like you would do in adults).

Circulation
(1)Access is often denied!!    
(a)Peripheral IVs or many times impossible because of the adiposity.
(b)Use a longer IO and make sure you SECURE IT!
(c)Use your U/S to assist with central lines (your landmarks are not easily identified).
(2)Chest Compressions…
(a)The most important part of CPR
(b)Ensure that you are doing effective compressions not merely compressing adiposity.
(3)Medications and Electric Cardioversion  
 (a)Both are weight based and both may be inappropriate for the obese patient

 (b)In the future there may be specific recommendations regarding necessary adjustments
 (c)For the time being, there are no alternative PALS algorithms for obese children

Srinivasan V, Nadkarni VM, Helfaer MA, Carey SM, Berg RA. Childhood Obesity and Survival After In-Hospital Pediatric Cardiopulmonary Resusication. Pediatrics: 2010 (125); e481-e488.

Kline AM. Pediatric Obesity in Acute and Critical Care. AACN Advanced Critical Care: 2008 (19); 38-46.

Brown CVR, Neville AL, Salim A, Rhee P, Cologne K, Demetriades D. The Impact of Obesity on Severely Injured Children and Adolescents. Journal of Pediatric Surgery: 2006 (41); 88-91